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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
FROM ADMISSION NOTE:
___ from ___ memory unit for evaluation of altered mental
status.
Per ED, she has baseline dementia, has had 1 week of increasing
inability to function at that facility, decreased feeding,
decreased communication and interactivity. Patient unable to
express hx, except not being in pain, all hx per ED was from
paperwork and facility. Per ED exam, dry mucous membranes,
bilateral arm tremulousness, with symmetrically tremulous grip
strength. EKG sinus at 84, normal axis, normal intervals, there
is no ST elevation or depression, there are no ischemic T-wave
changes; similar compared to prior.
Per ED, has hx TBI, dementia, and bipolar disorder.
Geriatrics fellow was called by ED, who recommended admission w/
iv abx.
Per nursing, was eval'd for AMS at ___. Had 1 week of
increasing inability to function at that facility, decreased
feeding, decreased communication and interactivity. Her son
stated that she was not being changed regularly.
I reviewed VS, labs, orders, imaging, old records, meds.
Past Medical History:
POBHx:
G1P1001
___ SVD no complications
PGynHx:
-LMP ___ years ago.
-Denies history of abnormal Pap tests.
-Last Pap ___ years ago.
-She is not sexually active.
-She has a history of genital herpes and gonorrhea.
PMH:
-HTN
-?Mild pulmonary hypertension, undergoing evaluation
-Fibromyalgia
-ADHD
-Depression
-Arthritis in low back and neck
PSH:
-Vaginal tubal ligation
Social History:
___
Family History:
Mother with ___ cancer. Multiple relatives with high
blood pressure and heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Vital Signs Reviewed (see eFlowsheet)
GENERAL: Alert, NAD
EYES: Anicteric, PERRL
ENT: MMM
Neck: Supple
CV: heart RRR, pulses distally intact. No ___ edema.
RESP: Lungs CTAB. No increased WOB. no accessory muscle use
GI: Abdomen soft, N/D, N/T. BS+
GU: No suprapubic tenderness
MSK: much more active and moving all extremities with good
strength
SKIN: heels in boots, L heel wound in boot.
NEURO: Alert, more conversant
PSYCH: alert
DISCHARGE PHYSICAL EXAM:
VS: Vital Signs Reviewed (see eFlowsheet)
GEN: Alert, NAD
EYES: Anicteric, PERRL
ENT: MMM
CV: RRR nl S1/S2 no g/r/m
RESP: Lungs CTAB. no w/r/r
GI: Abdomen soft, N/D, N/T. NABS
GU: No suprapubic tenderness
MSK: moving all extremities, globally weak but symmetric
strength
SKIN: heels in boots, L heel wound in boot.
NEURO: Alert, but not oriented. cooperative.
PSYCH: alert, talkative but pleasantly confused,
Pertinent Results:
___ - CBC - 16.5/11.7/37.7/480
BMP: BLOOD Glucose-110* UreaN-33* Creat-0.7 Na-146 K-4.5 Cl-105
HCO3-26 AnGap-15
Urine Culture:
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR:
Final Report
INDICATION: History: ___ with altered mental status// Evaluate
for pneumonia,
evaluate for intracranial hemorrhage
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are lower compared to the prior exam. The heart
size appears
normal and unchanged. The aorta is mildly tortuous.
Mediastinal and hilar
contours are otherwise similar. The pulmonary vasculature is
not engorged.
Apart from linear atelectasis in left lung base, the lungs
appear clear. No
pleural effusion or pneumothorax is detected. Clips are seen in
the right
upper quadrant of the abdomen. There are no acute osseous
abnormalities.
IMPRESSION: No radiographic evidence for pneumonia.
DISCHARGE LABS:
___ 07:11AM BLOOD WBC-8.0 RBC-3.57* Hgb-10.0* Hct-32.6*
MCV-91 MCH-28.0 MCHC-30.7* RDW-13.4 RDWSD-44.7 Plt ___
___ 07:11AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-96 UreaN-16 Creat-0.6 Na-139
K-4.0 Cl-101 HCO3-27 AnGap-11
___ 06:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Levothyroxine Sodium 50 mcg PO 3X/WEEK (___)
3. Sertraline 100 mg PO DAILY
4. Ranitidine 75 mg PO DAILY:PRN GERD
5. Levothyroxine Sodium 75 mcg PO 4X/WEEK (___)
6. Polyethylene Glycol 17 g PO DAILY:PRN constiatipon
7. Bisacodyl 10 mg PR QHS:PRN consttiaption
8. Milk of Magnesia 30 mL PO Q6H:PRN constiation
9. LORazepam 0.5 mg PO Q8H:PRN amxiety
10. LamoTRIgine 50 mg PO DAILY
11. Divalproex (DELayed Release) 250 mg PO DAILY
12. LORazepam 0.5 mg PO Q2PM
13. OLANZapine 5 mg PO BID
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*1 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Bisacodyl 10 mg PR QHS:PRN consttiaption
5. Divalproex (DELayed Release) 250 mg PO DAILY
6. LamoTRIgine 50 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO 3X/WEEK (___)
8. Levothyroxine Sodium 75 mcg PO 4X/WEEK (___)
9. Milk of Magnesia 30 mL PO Q6H:PRN constiation
10. OLANZapine 5 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constiatipon
12. Ranitidine 75 mg PO DAILY:PRN GERD
13. Sertraline 100 mg PO DAILY
14. HELD- LORazepam 0.5 mg PO Q2PM This medication was held. Do
not restart LORazepam until ___ speak with your PCP or ___
geriatric psych doctor
15. HELD- LORazepam 0.5 mg PO Q2PM This medication was held. Do
not restart LORazepam until ___ speak with your PCP or ___
geriatric psych doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
Altered Mental status
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - always.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with altered mental status// Evaluate for pneumonia,
evaluate for intracranial hemorrhage
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are lower compared to the prior exam. The heart size appears
normal and unchanged. The aorta is mildly tortuous. Mediastinal and hilar
contours are otherwise similar. The pulmonary vasculature is not engorged.
Apart from linear atelectasis in left lung base, the lungs appear clear. No
pleural effusion or pneumothorax is detected. Clips are seen in the right
upper quadrant of the abdomen. There are no acute osseous abnormalities.
IMPRESSION:
No radiographic evidence for pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with altered mental status. Evaluate for pneumonia, 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: DLP: 1495.94 mGy-cm.
COMPARISON: CT head of ___.
FINDINGS:
Images are degraded by patient motion and streak artifact. Within this
limitation, there is no evidence of acute intracranial hemorrhage,acute large
territorial infarction,edema,or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes, similar to the prior study.
There is no evidence of calvarial fracture. The inferior left mastoid air
cells are partially opacified, new since ___ is suggestive of mild
ongoing inflammation. The visualized portion of the paranasal sinuses, right
mastoid air cells,and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
Limited study due to significant patient motion and streak artifact. Within
this limitation, no evidence of acute intracranial hemorrhage or mass effect.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Failure to thrive
Diagnosed with Altered mental status, unspecified
temperature: 97.7
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 154.0
dbp: 94.0
level of pain: unable
level of acuity: 2.0 | Mrs ___ is a ___ year old woman with a history of HTN,
TBI, bipolar disorder, mild pulmonary HTN, chronic anemia,
fibromyalgia, ADHD, depression, arthritis from ___ memory
unit for AMS who was found to have a UTI and hypernatremia.
# Toxic Metabolic Encephalopathy: Patient admitted from ___
memory unit with altered mental status. NCHCT normal. CXR
without evidence of pneumonia. UA with pyuria and bacteriuria
and urine culture grew pansensitive Proteus. Home ranitidine
and Lorazepam were held as sedating. Patient's son describes
worsening nonverbal status over the past few months, which
occurred in the setting of uptitrating psychotropic medications.
Patient's mental status improved with antibiotic therapy and
correction of hypernatremia (see below) discussion with regular
caregivers at ___ was very close to her baseline mental
status prior to discharge.
# Proteus UTI: Urine cultures grew pansensitive Proteus in the
setting of AMS. Patient was initially started on meropenem,
then ceftriaxone and transitioned to TMP/SMX once final
sensitivity data was available. Patient's mental status
improved antibiotic therapy. Treated for a total 7 day course
of antibiotics given that she has had multiple recent UTIs.
Encouraged regular bladder hygiene, frequent diaper changes, and
bladder scans for retention once with returns to ___.
# Hypernatremia: N/A on admission 146 increased to 150 in the
setting of poor oral intake and not drinking free water.
Improved as patient's mental status returned closer to baseline
and was also given free water to return her back to normal
levels. Patient was eating and drinking regularly and without
assistance prior to discharge
# Hypoalbuminemia/protein calorie malnutrition: Nutrition
consulted while hospitalized started on multivitamin and Ensure.
# Bipolar disorder/fibromyalgia/ADHD/depression: Continued home
lamotrigine, depakote, sertraline, and olanzapine
- if fails to improve will consult neurology
# Hypothryoidism: TSH WNL. Continued home levothyroxine
TRANSITIONAL ISSUES
[ ] Patient to complete total 7 day course of antibiotics for
pansensitive Proteus UTI on ___.
[ ] Lorazepam was STOPPED this admission for AMS.
[ ] Patient noted to be on multiple psychotropic medications of
unclear benefit. Would recommend she be evaluated by ___ psych
in the near future de-escalate polypharmacy as able.
[ ] Given the patient has had multiple UTIs in the past few
weeks, would recommend regular diaper checks, diaper changes,
bladder hygiene encouragement, bladder scan monitoring on return
to ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
FROM ADMISSION NOTE
Ms. ___ is a ___ post-menopausal female with
minimal past medical history (pre-diabetes) who presents with
with several months history of chest pain, fevers found to have
a pericardial effusion who was transferred to ___ for further
management.
Patients symptoms began in in ___. She developed
recurrent (daily) episodes of burning chest pain, worse on
inspiration and when laying flat, accompanied by daily
fevers/chills/nightsweats. She initially was evaluated at ___
___ and diagnosed with pericarditis per patient
report. Ms. ___ believes she did not complete a course of
NSAIDs or colchicine for management of her pericarditis but was
noted to have a pericardial effusion. She was not evaluated by a
Cardiologist following ___ discharge. Onset in ___ was not
associated with any known trigger.
As part of her workup she was treated several times for
pneumonia and diagnosed with GERD, started on omeprazole. She
underwent EGD in the setting of GERD evaluation, which per
report did not demonstrate acute abnormalities. None of this
resolved her symptoms, although she reports some improvement in
her symptoms with a daily regimen of 20mg Omeprazole BID, 1000mg
Tylenol, ___ Ibuprofen taken up to 4x daily.
Since ___, patient reports her chest pain has not
resolved. She has had 6 "flares" in which the chest pain
worsens. There is no clear trigger for these flares. Associated
symptoms include daily fevers and dyspnea.
She has no recent sick contacts, no recent travel outside of the
___.
Her current presentation was prompted by worsening chest pain
and fatigue. She presented to the ___ where she was
found to have an elevated D-dimer. Initial chest xray was
concerning for bilateral infiltrates however CT Chest did not
demonstrate imaging concern for pneumonia but was concerning for
a moderate size pericardial effusion. There was no evidence of
PE.
In the ___, her vitals were 99.1 F (37.3 C). Pulse: 98.
Respiratory Rate: 19. Blood-pressure: 114/67. Oxygen Saturation:
96% room air; Normal. EKG was notable for twi inferiorly, V3-6;
twf flattening laterally Comparison: No old ECG available for
comparison.
Labs showed
- HGB: 9.9*, WBC: 17.9*, PLT: 454, MCV: 71.3
- ALT: 43, AP: 292, Alb: 3.7, AST: 33, TBili: 1.1, TProt: 7.1
- Na: 135*, Cl: 95*, Bun: 9, Glucose: 104, Anion Gap: 17, K+:
3.9, CO2: 23, Creat: 0.8
-TROPONIN T, information as of ___, 7:30 pm TROPONIN T: <
0.01 Ng/Ml
- D-DIMER: ___ Ng/Ml
- INFLUENZA A (RT-PCR): Neg;INFLUENZA B (RT-PCR): Neg
Studies showed:
CTA Chest: 1. No pulmonary embolus identified with limited
assessment of the peripheral branches.
2. Moderate pericardial effusion.
3. Left greater than right streaky consolidations versus
bibasilar
atelectasis.
She was given:
- metoclopramide Hcl 10mg
- Diphenhydramine 50mg
- Famotidine 20mg
- 1L NS
- Ketorolac 15mg
- Ceftriaxone 1g
On arrival to the CCU, she is awake, alert, and moderately
uncomfortable. She corroborated the above history. Reports her
current symptoms have increased in severity although she is
unclear of the trigger. Her chest pain is severe, mid sternal,
burning, radiating to throat. She reports associated dyspnea
with increased severity in her pain which occurs both at rest
and with activity.
REVIEW OF SYSTEMS: as per HPI
Past Medical History:
FROM ADMISSION NOTE
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Pre-Diabetes
2. CARDIAC HISTORY
- coronaries: No known coronary disease
- pumping function: No previous ECHO completed
- rhythm: Regular rate and rhythm
3. OTHER PAST MEDICAL HISTORY
-GERD
-Recurrent UTI
-Nicotine Dependence
Social History:
___
Family History:
FROM ADMISSION NOTE
Denies family history of known CAD, reports history of diabetes,
colon cancer in father, breast cancer in sister. No known
autoimmune history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: Reviewed in Metavision
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple
CARDIAC No murmur and RRR
LUNGS Resp Distress and Normal Breath Sounds
ABDOMEN: Non-tender and Soft
Neurological: Alert, Oriented X3 Skin: No rash, Warm and Dry
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: T 98.3, HR 75, BP 114/82, RR 16, O2 96% RA
GENERAL: NAD
HEENT: anicteric, MMM
NECK: supple, no thyromegaly
LYMPH: no cervical, supraclavicular, axillary lymphadenopathy
CV: RRR, S1/S2, no m/r/g
PULM: unlabored, CTAB
ABD: soft, normoactive, nondistended, nontender
EXT: WWP, without edema
NEURO: non-focal
SKIN: no rashes or nail changes
Pertinent Results:
ADMISSION LABS:
==============
___ 05:10AM BLOOD WBC-14.2* RBC-4.13 Hgb-9.1* Hct-29.2*
MCV-71* MCH-22.0* MCHC-31.2* RDW-14.8 RDWSD-37.2 Plt ___
___ 05:10AM BLOOD Neuts-82.7* Lymphs-6.1* Monos-9.4
Eos-0.4* Baso-0.4 Im ___ AbsNeut-11.73* AbsLymp-0.86*
AbsMono-1.33* AbsEos-0.05 AbsBaso-0.05
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD ___ PTT-31.4 ___
___ 05:10AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-136
K-4.0 Cl-98 HCO3-25 AnGap-13
___ 05:10AM BLOOD ALT-41* AST-31 AlkPhos-297* TotBili-0.9
___ 10:54AM BLOOD Iron-12*
___ 10:54AM BLOOD calTIBC-237* Ferritn-423* TRF-182*
___ 10:54AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-NEG
___ 10:54AM BLOOD HIV Ab-NEG
___ 10:54AM BLOOD HCV Ab-NEG
PERTINENT LABS:
==============
___ 10:54AM BLOOD CRP->300*
Test Result Reference
Range/Units
SED RATE BY MODIFIED 72 H < OR = 30 mm/h
___
DISCHARGE LABS:
==============
___ 05:10AM BLOOD cTropnT-<0.01
___ 05:10AM BLOOD TSH-2.4
___ 07:39AM BLOOD WBC-8.9 RBC-3.92 Hgb-8.7* Hct-28.0*
MCV-71* MCH-22.2* MCHC-31.1* RDW-15.1 RDWSD-38.7 Plt ___
___ 07:39AM BLOOD Glucose-88 UreaN-14 Creat-0.7 Na-142
K-4.1 Cl-100 HCO3-23 AnGap-19*
___ 07:39AM BLOOD ALT-68* AST-50* LD(LDH)-366* AlkPhos-449*
TotBili-0.5 DirBili-<0.2 IndBili-0.5
___ 07:39AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.5
IMAGING:
=======
OSH CT CHEST (___)
IMPRESSION:
1. No pulmonary embolus identified with limited assessment of
the peripheral branches.
2. Moderate pericardial effusion.
3. Left greater than right streaky consolidations versus
bibasilar atelectasis.
ECHO (___)
IMPRESSION: Small to moderate, echodense pericardial effusion
without echocardiographic evidence of tamponade.
SECOND OPINION CT CHEST (___)
IMPRESSION:
1. Moderate pericardial effusion with possible pericardial
enhancement
consistent with provided history of pericarditis. Associated
mediastinal
adenopathy is likely reactive.
2. No evidence of pulmonary embolism or acute aortic
abnormality.
3. Low lung volumes cause bibasilar platelike subsegmental
atelectasis.
4. Small left and trace right pleural effusions.
5. Retroperitoneal lymph nodes are increased in number but
normal in size and morphology, of uncertain etiology. Dedicated
abdominal imaging is recommended with a contrast-enhanced CT of
the abdomen and pelvis.
6. 3mm pulmonary nodules in the right upper and lower lobes.
RECOMMENDATION(S):
1. Nonemergent contrast-enhanced CT of the abdomen and pelvis.
2. For incidentally detected multiple solid pulmonary nodules
smaller than
6mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT follow-up in 12 months is recommended in a
high-risk patient. See the ___ ___ Guidelines
for the Management of Pulmonary Nodules Incidentally Detected on
CT" for comments and reference:
___
MICROBIOLOGY:
============
QUANTIFERON-TB GOLD (___)
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
Negative test result. M. tuberculosis complex infection
unlikely.
Test Result Reference
Range/Units
NIL 0.06 IU/mL
MITOGEN-NIL 0.78 IU/mL
TB-NIL 0.01 IU/mL
ASPERGILLUS GALACTOMANNAN ASSAY (___)
Test Result Reference
Range/Units
INDEX VALUE 0.34 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
2. Acetaminophen 1000 mg PO Q4H:PRN Pain - Severe
3. Omeprazole 20 mg PO BID
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Naproxen 500 mg PO BID
RX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Pericarditis, relapsing versus persistent with pericardial
effusion
SECONDARY:
-Anemia, microcytic
-Transaminitis
-Pulmonary nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SECOND OPINION CT TORSO
INDICATION: ___ female admitted for pericarditis/pericardial effusion
of uncertain etiology with incidental RLL pulmonary nodule and vague opacities
on outside hospital CTA, evaluate abnormalities.
TECHNIQUE: Study was obtained an outside hospital. Axial and the CT images
were acquired through the chest after the administration of IV contrast. 5 mm
axial reformatted in soft tissue and lung algorithm reconstructions as well as
1.5 mm axial reformats in soft tissue algorithm were provided and reviewed. 5
mm soft tissue algorithm coronal and sagittal reformats and 10 mm coronal and
sagittal MIPS images were provided and reviewed.
DOSE: Outside hospital total reported DLP = 460 mGy-cm.
COMPARISON: None available.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
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 a moderate pericardial effusion with areas of subtly
increased peripheral attenuation suggesting mild enhancement.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
PULMONARY PARENCHYMA: Low lung volumes cause bibasilar subsegmental patchy
atelectasis. A 3 mm nodule is noted in the peripheral right upper lobe
(6:72). A 3 mm nodule is noted in the peripheral right lower lobe (6:100). A
there is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: Pleural effusions are small on the left and trace on the right.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild.
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
numerous retroperitoneal lymph nodes, increased in number but normal in size
of uncertain etiology.
IMPRESSION:
1. Second read request for study performed and interpreted at outside hospital
- please correlate with outside hospital final report.
2. Moderate pericardial effusion with possible pericardial enhancement
consistent with provided history of pericarditis. Associated mediastinal
adenopathy is likely reactive.
3. No evidence of pulmonary embolism or acute aortic abnormality.
4. Low lung volumes cause bibasilar platelike subsegmental atelectasis.
5. Small left and trace right pleural effusions.
6. Retroperitoneal lymph nodes are increased in number but normal in size and
morphology, of uncertain etiology. Dedicated abdominal imaging is recommended
with a contrast-enhanced CT of the abdomen and pelvis.
7. 3mm pulmonary nodules in the right upper and lower lobes.
RECOMMENDATION(S):
1. Nonemergent contrast-enhanced CT of the abdomen and pelvis.
2. For incidentally detected multiple solid pulmonary nodules smaller than
6mm, no CT follow-up is recommended in a low-risk patient, and an optional CT
follow-up in 12 months is recommended in a high-risk patient. See the ___
___ Society Guidelines for the Management of Pulmonary Nodules
Incidentally Detected on CT" for comments and reference:
___
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 16:58 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Chest pain, Fever
Diagnosed with Pericardial effusion (noninflammatory), Chest pain, unspecified
temperature: 99.7
heartrate: 98.0
resprate: 16.0
o2sat: 95.0
sbp: 103.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Previously healthy ___ female with history of relapsing
fever and chest pain of estimated nine-month duration, once
attributed to pericarditis, now admitted for exacerbation of
said pain in association with small-to-moderate pericardial
effusion, which promptly resolved with empiric anti-inflammatory
agents.
#) Pericarditis, relapsing versus persistent
#) Pericardial effusion, small-to-moderate
ACS immediately excluded. Remained hemodynamically stable
without echocardiographic evidence of tamponade physiology,
suggestive of subacute to chronic accumulation. Etiology remains
uncertain. Inflammatory markers especially elevated. Fluid for
definitive diagnosis ultimately deemed unattainable. Infection,
in the context of vague pulmonary findings, is conceivable,
though protracted nature inconsistent with a pyogenic one. Brief
course of empiric antibiotics discontinued in that regard.
Tubercular type, moreover, unlikely in the absence of compelling
risk factors and symptoms to suggest active disease.
Importantly, Quantiferon-Gold negative. Uncertain how to
reconcile pulmonary findings with unifying diagnosis, though
smoldering fungal infection remains possible, albeit unlikely.
Fungal markers pending at discharge. Rheumatologic cause
likewise unlikely in the absence ___ or features of SLE among
other serositic diseases. Age-appropriate cancer unremarkable,
per patient report. Aforementioned all rendering
viral/idiopathic pericarditis probable. Chest pain promptly
resolved with combination antiinflammtory regimen--colchicine
0.6 mg BID and naproxen 500 mg BID. Minor leukocytosis of
neutrophilic predominance likewise resolved.
#) Anemia, microcytic: without tandem cytopenia. Suspect
reactive process in the context of inflammation. Iron studies in
keeping with anemia of inflammation. No evidence of hemorrhage.
Baseline hemoglobinopathy/thalassemia possible.
#) Transaminitis: likewise of uncertain etiology. Both infection
and malignancy conceivable, though never elucidated. No viral
hepatidities.
#) Pulmonary nodule, right lower lobe (3 mm): recommend 12-month
CT surveillance. Uncertain if first noted at ___ in ___ or
___. Per Patient PCP aware and planning on follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefpodoxime / Neurontin / Vicodin / latex / Sulfamide /
lidocaine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
cashews / spider bites
Attending: ___.
Chief Complaint:
L Inguinal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ hx AAA s/p EVAR ___ complicated by
type 4 endovascular leak, COPD, HLD who presents with left
hip/buttock pain with that started ___ when she woke up. The
patient had been doing well post-operatively after her AAA
repair up until this time. She describes the pain as a "bruise
feeling" and that her hip hurts worse with palpation. On ___
morning she also awoke to the same complaints. She also noted
tingling in her toes and a cold sensation to her left outer
thigh that was worse with movement and started walking with a
limp, prompting her to come to the ED. She denies any trauma or
falls. Of note, she has chronic nausea due to her multiple
abdominal surgeries but started dry heaving yesterday. She
denies abdominal pain, diarrhea, constipation, fevers/chills.
In the ED, initial vitals: 97.5 71 123/73 18 96% RA
Exam was notable for good pulses in the leg.
Labs were significant for WBC 12.6 H/H 10.0/31.6 Plt 649
INR 1.0
Na 139 K 4.5 Cl 106 HCO3 25 BUN 14 Cr 1.1, normal Ca/Mg/Phos
LFTS were unremarkable.
Urinalysis unremarkable.
Due to concern about potential buttock claudication, vascular
surgery was consulted.
Patient had a CT abd/pelvis which showed no evidence of endoleak
of endovascular repair of fusiform infrarenal AAA, patent
abdominal aortic major branches, pelvic and bilateral femoral
arterial vasculatue, no retroperitoneal or proximal thigh
hematoma. Mild intrahepatic biliary ductal and CBD dilation
(9-10mm, more prominent than prior), consider MRCP. Stable
4.9x3.2cm right adrenal mass (adenoma).
Patient was given 1L NS, a total of 12 mg ondansetron, 3 mg
dilaudid.
Currently, the patient reports slight nausea and pain that is
not too severe. She is anxious to leave the hospital and is
relieved that there is nothing wrong with her AAA repair.
ROS: + per HPI
Past Medical History:
-Hypercholesterolemia
-COPD
-arthritis
-spinal stenosis
-anxiety
-depression
-abdominal aortic aneurysm s/p EVAR ___
-pancreatitis
-Abdominal hysterectomy
-Groux-en-Y gastric bypass (___)
-right temporal artery biopsy (___)
-splenectomy (___)
-multiple abdominal wall hernia repairs, the most recent one a
couple of weeks ago
-prothrombin gene mutation (heterozygous)
Social History:
___
Family History:
Mother died age ___ from colon cancer, father died in his ___
from possible alcohol abuse. Multiple family members with
prothrombin
___ mutation
Physical Exam:
ADMISSION/DISCHARGE EXAM:
=========================
VS: 97.2 97/59 71 99%RA
GEN: Obese female sitting upright in a chair in NAD
HEENT: Adentulous, MMM, anicteric sclerae
NECK: Supple, no JVD
PULM: CTAB, no wheezes, rales or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Obese, soft, nontender, no organomegaly or masses
EXTREM: No edema. Tenderness to palpation of L hip, no
ecchymoses seen.
NEURO: CN II-XII intact. ___ strength in proximal and distal
lower and upper extremities bilaterally. Intact sensation
throughout. Slightly limping gait.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:20AM ___ PTT-29.0 ___
___ 03:20AM PLT COUNT-649*#
___ 03:20AM NEUTS-72.2* LYMPHS-16.5* MONOS-8.0 EOS-2.2
BASOS-0.5 IM ___ AbsNeut-9.08* AbsLymp-2.07 AbsMono-1.00*
AbsEos-0.28 AbsBaso-0.06
___ 03:20AM WBC-12.6* RBC-3.12* HGB-10.0* HCT-31.6*
MCV-101* MCH-32.1* MCHC-31.6* RDW-13.9 RDWSD-51.3*
___ 03:20AM ALBUMIN-3.4* CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-2.0
___ 03:20AM LIPASE-37
___ 03:20AM ALT(SGPT)-24 AST(SGOT)-19 ALK PHOS-105 TOT
BILI-0.1
___ 03:20AM estGFR-Using this
___ 03:20AM GLUCOSE-116* UREA N-14 CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
___ 06:15AM URINE MUCOUS-OCC
___ 06:15AM URINE HYALINE-3*
___ 06:15AM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 06:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
IMAGING/STUDIES:
================
+ ___ Imaging CTA ABD & PELVIS
FINDINGS:
VASCULAR: The patient is status post stent graft repair of an
infrarenal
abdominal aortic aneurysm. The excluded aneurysm sac measures
5.2 x 4.5 cm in axial ___, stable since prior from ___ when measured in a similar fashion. There is no
evidence of endoleak. The legs of the stents extend into the
distal common iliac arteries bilaterally.
The celiac axis is patent. The right hepatic artery is replaced
to the
proximal SMA. The SMA is patent throughout its course.
Bilateral renal arteries are patent. The ___ arises from the
excluded
aneurysm sac and is not opacified proximally, but is
reconstituted at its
midportion from collaterals. The bilateral common, external,
and internal
iliac arteries are patent and unremarkable. Mild fat stranding
surrounds the left common femoral artery, consistent with prior
percutaneous vascular access. Otherwise, the proximal imaged
femoral arterial vasculature is patent and unremarkable.
There is no evidence of retroperitoneal hematoma. There is no
evidence of
hematoma within the left thigh.
LOWER CHEST: A left Bochdalek hernia is noted, along with an
anterior
eventration with some fat. Scattered foci of centrilobular
emphysema are
noted in the right lung base. Otherwise, the partially imaged
lung bases are clear. Again seen is a small hiatus hernia.
There is no pericardial
effusion.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence
of concerning focal lesion. There is no intrahepatic biliary
ductal dilation. The portal vein is patent. More prominent
since prior is mild diffuse intrahepatic biliary ductal
dilation, along with prominence of the CBD measuring up to 9-10
mm, with normal tapering toward the ampulla. No obstructing
stone or mass is seen.
PANCREAS: The pancreas enhances homogeneously. There is no
peripancreatic
stranding or ductal dilation.
SPLEEN: The spleen is surgically absent.
ADRENALS: Again seen is the 4.9 x 3.2 cm right adrenal mass with
heterogeneous enhancement, previously demonstrated to be an
adenoma, not appreciably changed since prior. The left adrenal
gland is mildly thickened without a discrete nodule, similar in
appearance to prior.
URINARY: There is an unchanged appearance of bilateral foci of
renal
parenchymal scarring, reflective of prior inflammation or
infection.
Otherwise, there is normal symmetric renal enhancement. There
is no
hydronephrosis.
GASTROINTESTINAL: The patient is status post gastric bypass
surgery. The JJ anastomosis is visualized in the left hemi
abdomen, and appears unremarkable. Otherwise, non-dilated small
bowel loops are normal in course and caliber without evidence of
wall thickening or obstruction. The colon is unremarkable. The
appendix is normal.
LYMPH NODES: Scattered retroperitoneal and mesenteric lymph
nodes are not
pathologically enlarged by CT size criteria, unchanged.
There is no free intraperitoneal air or fluid.
CT PELVIS:
The imaged pelvic organs, including the bladder and terminal
ureters, are
unremarkable. 1 There is no pelvic sidewall, iliac chain, or
inguinal
lymphadenopathy. There is no free pelvic fluid.
MUSCULOSKELETAL: The abdominal and pelvic walls are within
normal limits. The
thoracolumbar vertebral bodies are normally aligned. No
concerning focal
lytic or sclerotic osseous lesions are identified.
IMPRESSION:
1. Status post endovascular repair of a fusiform infrarenal
abdominal aortic aneurysm. No evidence of endoleak.
2. Otherwise, patent abdominal aortic major branches, and patent
visualized pelvic and bilateral femoral arterial vasculature.
3. No retroperitoneal or proximal thigh hematoma.
4. Mild intrahepatic biliary ductal and CBD dilation, with CBD
measuring 9-10 mm, appears more prominent in comparison to
priors. Correlate with symptoms and/or laboratory abnormalities
in consideration of further imaging with MRCP or ultrasound.
5. Stable 4.9 x 3.2 cm right adrenal mass, previously
demonstrated to be an adenoma. Stable left adrenal gland
thickening without a discrete nodule.
+ ___ Imaging DX BILATERAL HIPS
FINDINGS:
No fracture, dislocation or erosion. Hip joint spaces are
relatively well
preserved. Trace degenerative spurring bilaterally. Small os
acetabula on the right. SI joints and pubic symphysis are
preserved. Aorto bi-iliac endograft stent projects over the
lower abdomen. Contrast is seen within the bladder from a
earlier same-day CT examination.
IMPRESSION:
No fracture or dislocation. Trace degenerative changes of
bilateral hips.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Citalopram 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Lorazepam 1 mg PO Q8H:PRN anxiety
5. Pantoprazole 40 mg PO Q24H
6. Sucralfate 1 gm PO TID
7. Acetaminophen 650 mg PO Q6H:PRN pain/fever
8. Aspirin EC 81 mg PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
10. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Lorazepam 1 mg PO Q8H:PRN anxiety
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Sucralfate 1 gm PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Left hip pain
Secondary diagnoses:
AAA s/p EVAR ___
COPD
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with s/p AAA repair, pain L leg/hip/abd, lobe
for vascular injury, retroperitoneal bleed.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous, and
delayed phase images were acquired through the abdomen and pelvis.
IV Contrast: 130mL of Omnipaque
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 1,497 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR: The patient is status post stent graft repair of an infrarenal
abdominal aortic aneurysm. The excluded aneurysm sac measures 5.2 x 4.5 cm in
axial ___, stable since prior from ___ when measured in a
similar fashion. There is no evidence of endoleak. The legs of the stents
extend into the distal common iliac arteries bilaterally.
The celiac axis is patent. The right hepatic artery is replaced to the
proximal SMA. The SMA is patent throughout its course.
Bilateral renal arteries are patent. The ___ arises from the excluded
aneurysm sac and is not opacified proximally, but is reconstituted at its
midportion from collaterals. The bilateral common, external, and internal
iliac arteries are patent and unremarkable. Mild fat stranding surrounds the
left common femoral artery, consistent with prior percutaneous vascular
access. Otherwise, the proximal imaged femoral arterial vasculature is patent
and unremarkable.
There is no evidence of retroperitoneal hematoma. There is no evidence of
hematoma within the left thigh.
LOWER CHEST: A left Bochdalek hernia is noted, along with an anterior
eventration with some fat. Scattered foci of centrilobular emphysema are
noted in the right lung base. Otherwise, the partially imaged lung bases are
clear. Again seen is a small hiatus hernia. There is no pericardial
effusion.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning
focal lesion. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. More prominent since prior is mild diffuse intrahepatic
biliary ductal dilation, along with prominence of the CBD measuring up to 9-10
mm, with normal tapering toward the ampulla. No obstructing stone or mass is
seen.
PANCREAS: The pancreas enhances homogeneously. There is no peripancreatic
stranding or ductal dilation.
SPLEEN: The spleen is surgically absent.
ADRENALS: Again seen is the 4.9 x 3.2 cm right adrenal mass with heterogeneous
enhancement, previously demonstrated to be an adenoma, not appreciably changed
since prior. The left adrenal gland is mildly thickened without a discrete
nodule, similar in appearance to prior.
URINARY: There is an unchanged appearance of bilateral foci of renal
parenchymal scarring, reflective of prior inflammation or infection.
Otherwise, there is normal symmetric renal enhancement. There is no
hydronephrosis.
GASTROINTESTINAL: The patient is status post gastric bypass surgery. The JJ
anastomosis is visualized in the left hemi abdomen, and appears unremarkable.
Otherwise, non-dilated small bowel loops are normal in course and caliber
without evidence of wall thickening or obstruction. The colon is
unremarkable. The appendix is normal.
LYMPH NODES: Scattered retroperitoneal and mesenteric lymph nodes are not
pathologically enlarged by CT size criteria, unchanged.
There is no free intraperitoneal air or fluid.
CT PELVIS:
The imaged pelvic organs, including the bladder and terminal ureters, are
unremarkable. 1 There is no pelvic sidewall, iliac chain, or inguinal
lymphadenopathy. There is no free pelvic fluid.
MUSCULOSKELETAL: The abdominal and pelvic walls are within normal limits. The
thoracolumbar vertebral bodies are normally aligned. No concerning focal
lytic or sclerotic osseous lesions are identified.
IMPRESSION:
1. Status post endovascular repair of a fusiform infrarenal abdominal aortic
aneurysm. No evidence of endoleak.
2. Otherwise, patent abdominal aortic major branches, and patent visualized
pelvic and bilateral femoral arterial vasculature.
3. No retroperitoneal or proximal thigh hematoma.
4. Mild intrahepatic biliary ductal and CBD dilation, with CBD measuring 9-10
mm, appears more prominent in comparison to priors. Correlate with symptoms
and/or laboratory abnormalities in consideration of further imaging with MRCP
or ultrasound.
5. Stable 4.9 x 3.2 cm right adrenal mass, previously demonstrated to be an
adenoma. Stable left adrenal gland thickening without a discrete nodule.
Radiology Report
EXAMINATION: DX BILATERAL HIPS
INDICATION: History of AAA status post endovascular repair presenting with
bilateral hip pain.
TECHNIQUE: Frontal view of the pelvis with two views each of the bilateral
hips.
COMPARISON: Same-day CTA abdomen and pelvis. CT torso ___.
FINDINGS:
No fracture, dislocation or erosion. Hip joint spaces are relatively well
preserved. Trace degenerative spurring bilaterally. Small os acetabula on
the right. SI joints and pubic symphysis are preserved. Aorto bi-iliac
endograft stent projects over the lower abdomen. Contrast is seen within the
bladder from a earlier same-day CT examination.
IMPRESSION:
No fracture or dislocation. Trace degenerative changes of bilateral hips.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Inguinal pain
Diagnosed with Pelvic and perineal pain
temperature: 97.5
heartrate: 71.0
resprate: 18.0
o2sat: 96.0
sbp: 123.0
dbp: 73.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ hx AAA s/p EVAR ___ complicated by
type 4 endovascular leak, COPD, HLD, COPD who presents with left
hip/buttock pain with coldness and tingling.
# Left inguinal/hip/buttock pain: Pt had a CT abdomen/pelvis
which showed no evidence of endoleak of endovascular repair of
fusiform infrarenal AAA, with patent abdominal aortic major
branches, pelvic and bilateral femoral arterial vasculature, no
retroperitoneal or proximal thigh hematoma. The patient endorsed
nausea which improved with 1L IVF as well as ondansetron. On
exam, the patient had tenderness to palpation of the lateral
left hip, without any focal neurological deficits. She was able
to walk without difficulty. Hip radiographs showed no evidence
of fracture. The patient stated that her symptoms felt better.
After discussion with the vascular service, it was determined
that her presentation was likely musculoskeletal in nature, such
as possibly hip bursitis. She felt better and wished to be
discharged.
# Dilated CBD: Pt found to have dilated CBD to 9-___bd/pelvis, new from prior. LFTs unremarkable, gallstone noted
on CT scan in colon. Given normal LFTs an acute episode of
choledocholithiasis unlikely. This was deferred for workup in
the outpatient setting.
# Heterogenous prothrombin gene mutation: In ___ pt was found
to have bilateral anterior tibial, left ___ and right peroneal
occlusive disease, thought to be secondary to possible embolic
phenomenon from known AAA vs. thromboembolic disease; pt was
started on warfarin at that time given family history of
prothrombin gene mutation. Patient states that she was tested
for prothrombin gene mutation and is heterogenous, and she was
told no longer needs to be on warfarin. Patient was not
discharged on warfarin after AAA endovascular repair.
# COPD: Continued home albuterol/Fluticasone-Salmeterol.
# HLD: Continued home atorvastatin.
# Depression/anxiety: Continued home citalopram.
# Hx gastric bypass: Continued home PPI and ondansetron PRN for
nausea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o F with a h/o ataxia due to idiopathic cerebellar disease
who is presenting for evaluation of fall ___ days ago and low
back pain. Pt was in ___ until ___, and was
diagnosed with a viral upper respiratory infection while there
(URI symptoms have resolved). On ___, she had generalized
weakness, and a fall while trying to lay back down on the bed,
without headstrike or LOC. She landed on her backside. She has
since had midline lumbar and paraspinal lumbar pain, getting
worse since then. XR in the ___ ___ negative. She
apparently had a physician visiting her home in the ___ ___ was
giving her IV Pain medications. She reports urinary incontinence
(cannot make the bathroom in time) and bowel incontinence as
well. Denies dysuria or hematuria.
In the ED she endorsed bowel and bladder incontinence, though
reportedly this was in the setting of racing to the bathroom and
being unable to make it in time. Denies n/v, though has had PO
intake.
In the ED, initial vitals were: 98.2, 84, 163/89, 18, 100% RA
Exam notable for: Neurologically intact, intact rectal tone
Labs notable for: WBC 18.3 with neutrophilia
Imaging notable for: CT spine with L1 compression fracture
Spine was consulted and recommended: TLSO, ___, pain control, OK
to eat
Patient was given: IV Morphine x2, IV Dilaudid x1
On the floor, confirms above story with no new complaints.
Past Medical History:
Ataxia secondary to progressive cerebellar degeneration of
unknown etiology
Appendectomy
Cholecystectomy
Hysterectomy
Hemicolectomy
Diverticular Disease
C-Section
Urticaria
Social History:
___
Family History:
N/A
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.3, 127 / 65, 72, 18, 97 RA
General: Alert, oriented x3, in obvious discomfort
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength bilateral lower extremities
but limited by pain. Normal sensation to pinprick bilateral
___.
DISCHARGE EXAM:
VS - 98.6 123/58 76 18 98%RA
General: Alert, oriented x3, NAD. Resting comfortably in bed.
HEENT: PERRL, MMM. No oropharyngeal erythema/exudates. EOMI. No
nystagmus appreciated.
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. Limited by brace.
Abdomen: Soft, non-tender, non-distended. +BS in lower abdomen.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength bilateral lower extremities
but limited by pain. Normal sensation to pinprick bilateral
___. Vertigo elicited with movement of head.
Back: Tender to palpation along L1 in spine, otherwise
nontender.
Pertinent Results:
ADMISSION LABS:
___ 09:00AM GLUCOSE-131* UREA N-15 CREAT-0.5 SODIUM-136
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 09:00AM WBC-18.6*# RBC-4.52 HGB-12.9 HCT-40.6 MCV-90
MCH-28.5 MCHC-31.8* RDW-15.0 RDWSD-49.5*
___ 09:00AM NEUTS-89.2* LYMPHS-7.5* MONOS-2.0* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-16.55* AbsLymp-1.40 AbsMono-0.37
AbsEos-0.00* AbsBaso-0.03
___ 09:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:00AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
INTERIM LABS:
___ 05:41AM BLOOD WBC-16.7* RBC-3.99 Hgb-11.5 Hct-36.1
MCV-91 MCH-28.8 MCHC-31.9* RDW-14.9 RDWSD-49.6* Plt ___
___ 05:41AM BLOOD ALT-30 AST-15 AlkPhos-78 TotBili-0.6
DISCHARGE LABS:
___ 07:09AM BLOOD WBC-12.1* RBC-4.04 Hgb-11.6 Hct-35.8
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.7 RDWSD-47.7* Plt ___
___ 07:09AM BLOOD Glucose-129* UreaN-11 Creat-0.4 Na-136
K-4.4 Cl-98 HCO3-25 AnGap-17
MICROBIOLOGY:
Drawn ___:
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 2047 ON ___
- ___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Daily surveillance blood cultures ___ remained no growth to
date.
IMAGING/STUDIES:
MRI L-Spine w/o Contrast (___)
IMPRESSION:
1. Acute/subacute compression fracture identified at superior
endplate of L1 as described detail above with minimal anterior
thecal sac the fed, extending towards the left pedicle with no
significant retropulsion.
2. Relatively stable and unchanged multilevel, multifactorial
degenerative changes throughout the lumbar spine.
CXR PA/Lateral ___:
IMPRESSION:
No acute intrathoracic process.
CT Lumbar Spine ___:
IMPRESSION:
1. 2 column L1 superior endplate compression deformity with
minimal bony retropulsion.
2. Degenerative disease involving the lower lumbar facet joints
with grade 1 anterolisthesis of L3 on L4.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Ibuprofen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day as needed Disp #*60 Capsule Refills:*0
2. Meclizine 12.5 mg PO TID:PRN vetigo, dizziness
RX *meclizine 12.5 mg 1 tablet(s) by mouth TID PRN Disp #*15
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth Every 4 hours as needed
Disp #*30 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID as needed
Disp #*60 Tablet Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
6. Omeprazole 40 mg PO DAILY
7.Outpatient Physical Therapy
Diagnosis: L1 Spinal Fracture
ICD-10: S32.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
L1 Compression Fracture
Ataxia secondary to progressive cerebellar degeneration of
unknown etiology
Secondary Diagnosis:
Appendectomy
Cholecystectomy
Hysterectomy
Hemicolectomy
Diverticular Disease
C-Section
Urticaria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: History: ___ with Lumbar pain s/p fall, now with urinary
incontinence/ bowel incontinence IV contrast to be given at radiologist
discretion as clinically needed // cauda equine syndrome? cord compression?
TECHNIQUE: Sagittal T1, T2 and sagittal STIR sequences were obtained through
the lumbar spine, axial T2 weighted images were also obtained.
COMPARISON: MRI of the lumbar spine dated ___.
FINDINGS:
Acute/subacute compression fracture is identified at L1 vertebral body
involving the superior endplate, producing minimal mass effect in the thecal
sac, and no significant retropulsion, apparently extending towards left
pedicle and with approximately 30% of the vertebral body height loss.
Unchanged heterogeneous signal is noted at T12 vertebral body consistent with
non expansile hemangioma. The conus medullaris is normal and terminates at
the level of T12/L1.
At T12/L1 level, there is diffuse disc bulge with no evidence of neural
foraminal narrowing or spinal canal stenosis.
At L1/L2l, there is no significant spinal canal stenosis or neural foraminal
narrowing, mild articular joint facet hypertrophy is present and grossly
unchanged.
At L2/L3, there is no evidence of neural foraminal narrowing or spinal canal
stenosis, mild articular joint facet hypertrophy is seen.
At L3/L4, there is unchanged diffuse disc bulge, causing minimal anterior
thecal sac deformity and mild bilateral neural foraminal narrowing, contacting
the traversing nerve roots bilaterally, moderate articular joint facet
hypertrophy and ligamentum flavum thickening are unchanged.
At L4/L5, there is disc desiccation and diffuse disc bulge, causing mild
bilateral neural foraminal narrowing, contacting the traversing nerve roots
bilaterally, moderate articular joint facet hypertrophy remains stable.
At L5/S1, disc degenerative changes with narrowing of the intervertebral disc
space and spondylosis are re- demonstrated, associated with disc bulge and
narrowing of the left neural foramen, contacting the traversing nerve roots
and apparently the left exiting nerve root of L5, moderate articular joint
facet hypertrophy is unchanged.
The sacroiliac joints and the visualized paravertebral structures are
unremarkable.
IMPRESSION:
1. Acute/subacute compression fracture identified at superior endplate of L1
as described detail above with minimal anterior thecal sac the fed, extending
towards the left pedicle with no significant retropulsion.
2. Relatively stable and unchanged multilevel, multifactorial degenerative
changes throughout the lumbar spine.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 12:40 ___, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with recent URI like symptoms, with elevated WBC in ED today
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ with fracture of L spine
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 800 mGy-cm.
COMPARISON: Prior lumbar spine MRI from earlier same day.
FINDINGS:
There is an acute fracture involving the superior endplate of L1 there is
involvement of the anterior and middle columns with minimal bony retropulsion
into the central spinal canal. Minimal surrounding perivertebral hematoma
noted. There is also mild loss of vertebral body height at L1. No additional
fracture is seen. Significant degenerative disc disease at L5-S1 with near
complete loss of disc space. Significant facet arthropathy at L3-4, L4-5 and
L5-S1. Grade 1 anterolisthesis of L3 relative to L4 noted. Otherwise
alignment is preserved. Bone mineralization is normal.
IMPRESSION:
1. 2 column L1 superior endplate compression deformity with minimal bony
retropulsion.
2. Degenerative disease involving the lower lumbar facet joints with grade 1
anterolisthesis of L3 on L4.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, Lower back pain
Diagnosed with Unsp fracture of first lumbar vertebra, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 163.0
dbp: 89.0
level of pain: 10
level of acuity: 2.0 | This is a ___ female with PMHx progressive cerebellar
disorder of unknown etiology who presented to the ED with low
back pain, found to have compression fracture of L1 vertebrae
after a fall one week prior. Patient was seen by the Spine team
who recommended TLSO brace. Patient was given oxycodone ___
Q4hrs PRN with good control of pain. Patient was evaluated by
physical therapy who recommended rehab. However, placement was
complicated by patient's current lack of health insurance, and
she was ultimately discharged home with free ___ ___.
# L1 Fracture: Patient presented to the ED for evaluation of low
back pain s/p mechanical fall from standing on to a bed. She has
a history of chronic back pain ___ degenerative changes, however
her pain was acutely worsened following her fall. MRI and CT of
the lumbar spine showed acute on chronic L1 compression
fracture. Ortho spine team was consulted that recommended TLSO
brace. Patient was admitted to be fitted for the brace and for
pain control. She remained neurologically intact with no signs
of cord compression throughout the admission. Pain was
controlled with PRN oxycodone and acetaminophen. Given concern
for osteoporosis/pathological fracture given the low impact of
the patient's reported fall, she was started on VitaminD 1000mg
daily. Physical therapy evaluated the patient and recommended
___ rehab, however, since the patient was uninsured, the
decision was made to arranged for 2 sessions of home ___. Patient
was discharged home with a short script for oxycodone and her
TLSO brace to follow up in 1 week with her PCP.
# Staphlococcus Bacteremia: On hospital day 1 of admission,
blood cultures obtained the previous day in the ED grew gram
positive cocci in clusters in 1 out of 4 bottles drawn. Patient
was started empirically on vancomycin. Daily surveillance
cultures were drawn without any further growth. Final speciation
of the positive bottle showed coagulase negative staph, most
consistent with skin flora contaminant. Throughout, patient
remained afebrile and hemodynamically stable. Therefore,
vancomycin was discontinued and patient continued to do well
without antibiotic therapy.
#Leukocytosis: On admission, patient was also found to have a
leukocytosis with a WBC count of 18. CT/MRI imaging were
negative for signs of osteomyelitis. UA was negative for signs
of infection. CXR was negative for PNA. Patient did report
history of flu-like, upper respiratory infection that began
approximately 1 week prior to arrival. Her symptoms were
resolving. Her bacteremia was felt to be a skin flora
contamination to blood cultures. Therefore, it was felt
leukocytosis was a possible stress response to her fracture vs
residual abnormality from a presumed viral illness prior to
admission. Patient remained afebrile. No other intervention was
pursued.
#Vertigo: Patient has a history of chronic cerebellar
dysfunction. On hospital day 5, she began to complain of vertigo
and dizziness, consistent with vertigo she had had in the past.
The vertigo was worst with positional changes and head movement.
Denies nausea/vomiting. Neuro exam was repeatedly negative for
other abnormalities. Symptoms were felt to be secondary to her
chronic cerebellar dysfunction. She was given PRN meclizine with
good effect and discharged with a short prescription of
meclizine until she was able to follow up with her PCP.
# GERD: Chronic issue. Continued on home dose of omeprazole
without active issues. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline / Zithromax /
Keflex / Macrodantin / Macrobid / Avelox / penicillin G /
Generic Cipro / Bee stings / Augmentin / sumatriptan
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with PMHx notable for
recurrent UTI/pleo s/p Right total and Left partial nephrectomy,
Asthma, HTN, HLD, diet controlled DM and recurrent admissions
for abdominal pain who presents with 5 days of abdominal pain
and 1 day of nausea. She reports that she was in her usual state
of health until the ___ prior to admission when she started
to develop LLQ abdominal pain. She reports that the pain is
sharp and stabbing in nature, is always present and radiates to
the back. She reports that this pain is similar to prior
presentations for which she was hospitalized with abdominal
pain. She reports that she last had a bowel movement on the day
the pain stated but has continued to pass gas. She reports that
she tried to continue to eat but the food made the pain worse.
She reports that she tried Tylenol but that did not help the
pain. She reports that the nausea started the day prior and she
ha 1 episode of NBNB emesis. She reports that at that point she
presented to the ED.
In the ED the patient underwent a CT scan of the abdomen that
was unrevealing for the cause of the pain. She contuined to have
the pain and was observed overnight. When the pain continued to
be present in the morning she was admitted to the medical
service for continued abdominal pain.
On arrival to the floor the patient reports that she continues
to have the abdominal pain and it is unchanged.
ROS:
A 10 point ROS was conducted and was negative except as above in
the HPI.
Past Medical History:
Recurrent UTI/pyelonephritis s/p R total and L partial
nephrectomies
CKD s/p nephrectomies
Asthma/Bronchitis
Tracheobronchomalacia
HTN
HLD
Hypothyroid
glucose intolerance
OSA
Osteoarthritis
Glaucoma
Pancreatic Cysts (IMPN)
Extensive Healthcare Utilization
Endocarditis
Multiple sclerosis/Optic Neuritis ___
Recurrent nephrolitiasis s/p multiple lithotripsies
Blood clots
- ___, L cephalic v thrombosis of IV line or port
- ___, LIJ-assoc nonocclusive thrombus
- ___ L peroneal clot post spinal surg, started on
warfarin
- ___ GI bleeding -> was taken off warfarin
Social History:
___
Family History:
Mother - deceased from breast Ca, age ___
No diabetes, coronary disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6, 154/85, 78, 18, 96%RA
GEN: On entering the room the patient was laying in bed. She
would occasionally roll in pain while clutching her abdomen.
HEENT: MMM, OP clear, EOMI, sclera anicteric.
NECK: Supple
CV: RRR
RESP: CTAB
ABD: +BS, soft, diffusely tneder to palpation, worse in LLQ.
GU: no foley
EXT: No ___ edema
SKIN: warma dn dry
NEURO: Fluent speach
PSYCH: Normal affect, A&Ox3
DISCHARGE PHYSICAL EXAM:
Vitals: 98.7, 154/82, 60, 18, 99%RA
GEN: Sitting up on the bed and walking around the room.
Pleasant.
HEENT: MMM, OP clear, EOMI, sclera anicteric.
NECK: Supple
CV: RRR
RESP: CTAB
ABD: +BS, soft, mildly tender to palpation, worse in LLQ.
GU: no foley
EXT: No ___ edema
SKIN: warma dn dry
NEURO: Fluent speach
PSYCH: Normal affect, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 08:27AM BLOOD WBC-8.8 RBC-4.61 Hgb-12.4 Hct-38.8 MCV-84
MCH-26.9 MCHC-32.0 RDW-14.9 RDWSD-44.1 Plt ___
___ 08:27AM BLOOD Neuts-75.3* Lymphs-17.6* Monos-6.2
Eos-0.2* Baso-0.2 Im ___ AbsNeut-6.65* AbsLymp-1.55
AbsMono-0.55 AbsEos-0.02* AbsBaso-0.02
___ 02:45PM BLOOD ___ PTT-31.2 ___
___ 08:27AM BLOOD Glucose-109* UreaN-23* Creat-1.1 Na-140
K-4.0 Cl-103 HCO3-24 AnGap-17
___ 08:27AM BLOOD ALT-20 AST-27 AlkPhos-127* TotBili-0.2
___ 08:27AM BLOOD Lipase-30
___ 08:27AM BLOOD Albumin-4.3
___ 09:55AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING:
___:
CT ABD/PELVIS:
IMPRESSION:
1. No evidence of hydronephrosis or obstructing renal calculus.
Patient is
status post right nephrectomy and partial nephrectomy of the
left kidney.
2. Diverticulosis without evidence of diverticulitis. The
patient is status
post right colectomy.
3. Left lower lobe pulmonary nodules are stable from ___.
4. Multiple pancreatic cystic lesions are consistent with IPMNs
and better
characterized on MR ___.
DISCHARGE LABS:
___ 06:56AM BLOOD WBC-5.8 RBC-4.06 Hgb-11.3 Hct-34.8 MCV-86
MCH-27.8 MCHC-32.5 RDW-14.8 RDWSD-44.9 Plt ___
___ 06:56AM BLOOD Glucose-93 UreaN-12 Creat-1.0 Na-140
K-4.4 Cl-103 HCO3-24 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cardizem CD 360 mg oral daily
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Lisinopril 10 mg PO QHS
5. Montelukast 10 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h:prn sob, wheeze
8. Rosuvastatin Calcium 20 mg PO QPM
9. Senna 8.6 mg PO QHS
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
11. azelastine 1 spray nasal daily
12. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
13. Lumigan (bimatoprost) 0.01 % ophthalmic ___
14. potassium citrate 10 mEq (1,080 mg) ORAL BID
15. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Cardizem CD 360 mg oral daily
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Lisinopril 10 mg PO QHS
6. Montelukast 10 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Senna 8.6 mg PO QHS
10. Simethicone 125 mg PO TID:PRN abdominal pain
RX *simethicone 125 mg 1 Capsule by mouth three times a day Disp
#*90 Capsule Refills:*0
11. azelastine 1 spray nasal daily
12. Fosfomycin Tromethamine 3 g PO EVERY 10 DAYS
13. Lumigan (bimatoprost) 0.01 % ophthalmic ___
14. potassium citrate 10 mEq (1,080 mg) ORAL BID
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h:prn sob, wheeze
16. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
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: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with L leg swelling // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: ___ ultrasound.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ w/hx of stones, s/p colectomy, please perform CT abd/pelvis
with and without contrast -- the patient has a Cr 1.1, has "one half a kidney
left," received 2L NS so far // ___ w/hx of stones, s/p colectomy, please
perform CT abd/pelvis with and without contrast -- the patient has a Cr 1.1,
has "one half a kidney left," received 2L NS so far
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique. IV
Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: ___
COMPARISON: CTU ___
FINDINGS:
LOWER CHEST: The 3 mm nodule the left lung base is unchanged from ___ (series 2, image 4). A 2 mm nodule at the left lung base (series 2,
image 2) is unchanged from ___. The lungs are otherwise clear.
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: Multiple pancreatic cystic lesions are unchanged in consistent with
IPMNs. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is a small splenule at the hilum of the
spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The patient is status post right nephrectomy and partial left. There
is hypertrophy of the remaining left kidney. Punctate sub mm nonobstructing
renal stones are noted. Metallic artifact at the left renal hilum is likely
from prior nephrectomy.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The patient
status post right colectomy. Diverticulosis of the sigmoid colon without
evidence of diverticulitis is unchanged.
PELVIS: There is a small diverticulum of the urinary bladder, otherwise 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. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
The patient status post posterior spinal fusion.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of hydronephrosis or obstructing renal calculus. Patient is
status post right nephrectomy and partial nephrectomy of the left kidney.
2. Diverticulosis without evidence of diverticulitis. The patient is status
post right colectomy.
3. Left lower lobe pulmonary nodules are stable from ___.
4. Multiple pancreatic cystic lesions are consistent with IPMNs and better
characterized on MR ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Noninfective gastroenteritis and colitis, unspecified
temperature: 96.4
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 189.0
dbp: 76.0
level of pain: 9
level of acuity: 3.0 | Pt is a ___ y.o woman with h.o recurrent pyelonephritis s/p
partial nephrectomies, CKD, asthma, HTN, hypothyroid, IPMNs, MS,
history of clots who presents with nausea, vomiting, and
abdominal Pain.
# Abdominal Pain - The patient presents with LLQ abdominal pain.
She reports that the pain is similar to her prior episodes of
abdominal pain. She has been admitted one other time this year
for this pain and she had 6 admission in the prior calendar year
for the same pain. She had a CT ABD/Pelvis that is negative for
acute pathology. She had not had a bowel for several days prior
to admission. On review with the radiologist there was not a
large fecal load. She was iniatlly managed with IV and PO
morphine and PO Tylenol. She was seen by the GI consult team who
recommended stopping the narcotics, continuing Tylenol, bowel
regimen, and to advance her diet. She continued to report the
same pain but it was unchanged on or off the narcotics. She was
able to tolerate a regular diet and was only on PO Tylenol. She
was stable for discharge. She will follow up with both her PCP
and GI as an outpatient.
# Nausea/vomiting: Patient reports N/V for 24 hours prior to
admission. Nothing further on admission. She was able to
tolerate a regular diet.
# HTN
- Continued home Dilt
# CKD Stage ___ (eGFR on admission of 50): At baseline
- Trended Creatine
- Avoided nephrotoxins
# Diet Controlled DM2:
- Low dose HISS and ___ QACHS as an inpatient. She required no
insulin in the hospital. She returned to her outpatient diet
control as an outpatient.
# Hypothyroidism
- Continued home meds
# HLD::
- Continued home statin
# Asthma
- Continued home meds |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Doxycycline / Shellfish
Attending: ___.
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old female with a history of chronic
abdominal pain and polysubstance abuse presented to the ED with
abdominal pain for the third day in a row requesting admission
for inability to tolerate PO for the two days prior to
admission. She was admitted ___ for abdominal pain;
during her admission she was actively withdrawing, no cause was
found for her pain. A CT was normal and EGD showed gastritis but
not thought to be significant enough to be causing pain. The day
of her last discharge, she had about 5 shots of hard alcohol,
and from that day until the current admission, she has had ___
drink per day, with her last drink the day prior to
presentation. She had also continued to take benzodiazepines; on
day of admission she had 4mg ativan and 1.5mg clonopin. She said
she is "done with alcohol", but does not want to stop the
benzos. She also smokes marijuana, but denied IVDU. Per records,
she also abuses opiates. She had started lyrica after her last
admission for her abdominal pain but it was "not helping." She
said she had been having her usual abdominal pain for the 2 days
prior to admission, except it more intense than usual. It was
described as epigastric, dull, ___ in intensity. It was worse
with lying down, better in the fetal position, and accompanied
by nausea and dry heaves which have prevented significant food
or liquid intake.
Past Medical History:
Chronic abdominal pain
Alcoholism, polysubstance abuse
Depression
Asthma
Social History:
___
Family History:
No fhx of pancreatic problems.
Maternal grandfather and aunt with late onset colon cancer.
Paternal grandmother with melanoma died age ___.
Father with MI, CVA, DM.
Physical Exam:
Physical exam on admission:
VS T 97.7, BP 106/72, HR 67, RR 18, O2 sat 99% RA
GEN Alert, oriented, does not appear to be in any pain, slightly
tremulous
HEENT NCAT, pupils 5mm->3mm, no nystagmus MMM, sclera anicteric,
OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft ND, tender to light palpation in upper abdomen (LUQ,
RUQ, epigastrium), normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal.
SKIN no ulcers or lesions
.
Physical exam on discharge:
Pertinent Results:
Labs on admission:
___ 07:25PM BLOOD WBC-7.5 RBC-4.65 Hgb-15.1 Hct-44.9 MCV-97
MCH-32.5* MCHC-33.6 RDW-13.0 Plt ___
___ 07:25PM BLOOD Glucose-87 UreaN-7 Creat-0.9 Na-142 K-4.2
Cl-101 HCO3-25 AnGap-20
___ 07:25PM BLOOD ALT-70* AST-44* AlkPhos-59 TotBili-0.6
___ 07:25PM BLOOD Lipase-47
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Montelukast Sodium 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Sucralfate 1 gm PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
9. Pregabalin 150 mg PO BID
Titrating up to 150mg TID if tolerated
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. FoLIC Acid 1 mg PO DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Sucralfate 1 gm PO BID
8. Thiamine 100 mg PO DAILY
9. Pregabalin 150 mg PO BID
Titrating up to 150mg TID if tolerated
10. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 15 Doses
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Inability to tolerate by mouth
Chronic abdominal pain
Secondary diagnoses:
Alcohol addiction
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with chronic abdominal pain, now presents with
acute epigastric pain.
COMPARISON: CT of the abdomen and pelvis ___.
FINDINGS: The liver is normal in echotexture, without focal lesions. There
is no intra- or extra-hepatic biliary dilatation. The common bile duct is
normal measuring 3 mm. The main portal vein has normal hepatopetal flow. The
pancreatic head and tail are obscured by overlying bowel gas. The distal CBD
is not visualized in the study.
IMPRESSION: Normal appearance of the liver and gallbladder without evidence
of biliary dilation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, DEHYDRATION, NAUSEA, CHRONIC PANCREATITIS
temperature: 98.5
heartrate: 117.0
resprate: 18.0
o2sat: 99.0
sbp: 147.0
dbp: 92.0
level of pain: 9
level of acuity: 3.0 | The patient is a ___ year old female with history of alcohol and
drug abuse and chronic abdominal pain, recently admitted for
flare, now presenting with vomiting and inability to tolerate
po's in setting of typical chronic abdominal pain.
.
ACUTE ISSUES
#Nausea/vomiting:
Patient with exam consistent with her chronic abdominal pain and
no concern for acute abdomen in setting of stable vital signs
and unremarkable labs. Patient was not experiencing nausea and
vomiting upon previous discharge, but reported that she was
unable to tolerate po intake since being discharged last time.
She reports that the nausea symptoms are worse with flares in
the pain. The patient was given ondansetron while admitted and
slowly advanced to clears and then regular diet. Her family
brought in baby food which she believed she tolerated well.
.
#Chronic abdominal pain:
Patient with history of chronic abdominal pain. Last admission,
patient had normal CT abdomen with normal lipase and EGD with
only mild gastritis, not thought to be causing the symptoms. The
patient has used a variety of drugs in the past including
heroin, Dilaudid, and Percocet, both prescribed and purchased on
the street. She has been previously on suboxone and methadone
for addiction which she reports offered some pain relief, but
only in large doses. The patient has not had any diarrhea or
bowel changes, vomiting was not witnessed while inpatient.
.
#Polysubstance abuse:
The patient has an extensive substance abuse history including
alcohol, heroin, and various narcotics in addition to
benzodiazepines and marijuana. Patient had been previously sober
on etOH but relapsed in ___. She was using heroin and
crushed Dilaudid for pain, and for a time was on suboxone and
methadone. Upon admission, her possessions were searched by
security which yielded benzos, marijuana, and alcohol. The
patient did not experience withdrawal symptoms while inpatient,
with CIWA scores consistently <10. The psychiatric liaison team
visited the patient to discuss drug/alcohol history and to
assess for willingness to enter rehab. The medical team also
made multiple recommendations about the need for ___
rehab, but given the functionality of the patient (she has
continued to work, and even be promoted while using substances),
she is unwilling to commit to this type of treatment.
.
#Vague neurologic/psychiatric symptoms:
The patient reported frequent visual and auditory hallucinations
and ataxia during her hospital stay. During her previous
admission, the patient had similar hallucinations which were
thought to be alcoholic hallucinosis per psychiatry, and started
on Haldol. This admission, the patient revealed that she had
tried to get Haldol from her PCP and was exhibiting Haldol
seeking behavior here. The patient also reported narrow-gait
ataxia, despite a completely normal neurologic exam (no deficits
in ___ sensation, normal DTR's, no dysmetria or cerebellar
signs). While the patient frequently demonstrated this ataxia in
view of the medical staff, the patient was observed by both
nursing and the medical staff to walk without ataxia when she
didn't realize she was being observed. She was evaluated by
psych for her continued hallucinations, and they thought this
could still be alcoholic hallucinosis despite her lack of
withdrawal. Finally, the patient was evaluated by psych for
possible suicidal ideation. She made comments to the attending
physician about her willingness to overdose if discharged and
was also found one morning with a noose tied around her neck.
She described the first situation to be hyperbole and the second
situation to be "artistic expression". Psychiatry did not
believe she was exhibiting true suidicidal ideations. Patient
was monitored for additional siutations.
.
CHRONIC ISSUES
#Asthma:
Patient with history of asthma, on home medication regimen. She
did not have any exacerbations or wheezing on exam while
inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Iodine Containing Multivitamin
Attending: ___
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M to F pre-op transgender hx of HIV+ (last CD4 425 in ___
presents with 4 weeks of nausea/vomiting/abdominal pain, found
to have transaminitis and acute renal failure. Patient reports
that for the past 4 weeks, she has had persistent
nausea/vomiting triggered by food intake. She states that she
has only been able to keep down water and a small amount of
food. She states she has lost a significant amount of weight.
She also describes periumbilical abdominal pain, which she is
not sure of any exacerbating factors. She denies any
fevers/chills, change in UOP, hematuria, dysuria, constipation,
diarrhea, melena, hematochezia, change in color of stool,
jaundice. She does state that her skin has gotten lighter.
Of note, patient has been taking premarin for the past 3 months.
She has also been taking the supplements "Breast Rx" and
"Bountiful Breast", which she purchased on-line. These
supplements contain bovine ovary and pituitary derivatives,
among other unknown ingredients. She was evaluated at the
___ ED on ___.
Labs there showed AST 230, ALT 406 Alk phos 162, K+ 2.9, Cr
3.28. Patient refused admission at that time. Today she
presented to the ___ and was transferred here for
evaluation of persistent laboratory abnormalities.
In the ED, initial vs were: 98.2 95 129/95 16 96% RA.
Labs were remarkable for ALT 274, AST 219, AP 136, HCT 33.1, K+
2.9, Cr 3.1.
Past Medical History:
HIV+ (last CD4 425 in ___, diagnosed in ___
Bladder surgery when 14 hrs old. Presented with polyria and
incontinence. Per patient, bladder looked like ___ mouse" on
imaging and two outpouchings were removed.
Social History:
___
Family History:
Adopted
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 122/94 93 18 100% RA
General: Alert, oriented, no acute distress, very thin
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-distended, tender to palpation in
periumbilical area. hypoactive bowel sounds, hepatomegaly with
liver edge extending 5cm below costal margin. no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No jaundice
Neuro: CNII-XII intact. No focal deficits. No asterixis.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 122/89 67 20 100%RA
General: Alert, oriented, no acute distress, very thin
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-distended, non-tender. hypoactive bowel
sounds, hepatomegaly with liver edge extending 5cm below costal
margin. no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No jaundice
Neuro: No focal deficits.
Pertinent Results:
LABS:
___ 04:20PM BLOOD WBC-4.9 RBC-3.68* Hgb-11.3* Hct-33.1*
MCV-90 MCH-30.6 MCHC-34.0 RDW-15.0 Plt ___
___ 06:45AM BLOOD WBC-3.5* RBC-3.62* Hgb-11.2* Hct-33.6*
MCV-93 MCH-30.8 MCHC-33.2 RDW-15.3 Plt ___
___ 07:30AM BLOOD ___ PTT-31.2 ___
___ 04:20PM BLOOD WBC-4.9 Lymph-17* Abs ___ CD3%-83
Abs CD3-688 CD4%-38 Abs CD4-319* CD8%-42 Abs CD8-351 CD4/CD8-0.9
___ 07:30AM BLOOD Ret Aut-1.8
___ 04:20PM BLOOD Glucose-93 UreaN-24* Creat-3.1*# Na-142
K-2.9* Cl-113* HCO3-17* AnGap-15
___ 09:10PM BLOOD Glucose-90 UreaN-24* Creat-3.0* Na-138
K-3.4 Cl-113* HCO3-17* AnGap-11
___ 07:30AM BLOOD Glucose-85 UreaN-20 Creat-2.6* Na-138
K-3.5 Cl-116* HCO3-15* AnGap-11
___ 07:15AM BLOOD Glucose-83 UreaN-15 Creat-2.2* Na-139
K-3.6 Cl-115* HCO3-16* AnGap-12
___ 06:45AM BLOOD Glucose-92 UreaN-14 Creat-2.2* Na-139
K-3.2* Cl-111* HCO3-20* AnGap-11
___ 04:20PM BLOOD ALT-274* AST-219* AlkPhos-136*
TotBili-0.4
___ 07:30AM BLOOD ALT-238* AST-189* AlkPhos-118 TotBili-0.4
___ 06:45AM BLOOD ALT-212* AST-133* AlkPhos-134*
TotBili-0.3
___ 04:20PM BLOOD Lipase-57
___ 04:20PM BLOOD Albumin-4.3 Calcium-8.7 Phos-1.8* Mg-1.9
___ 07:30AM BLOOD Albumin-3.8 Calcium-7.9* Phos-1.5* Mg-1.7
Iron-78
___ 06:45AM BLOOD Calcium-8.6 Phos-1.8* Mg-1.6
___ 07:30AM BLOOD calTIBC-252* ___ Ferritn-423*
TRF-194*
___ 07:30AM BLOOD TSH-2.6
___ 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:30AM BLOOD HCV Ab-NEGATIVE
URINE
UreaN Creat Na K Cl Phos Prot/Cr Albumin Alb/Cre
82 13 ___ <5.1 1.3 3.3 253.8
=====================================================
IMAGING/OTHER STUDIES:
RUQ U/S ___:
FINDINGS: The liver is normal in echotexture without focal
lesion, intra or extrahepatic biliary ductal dilatation. The
portal vein is patent with
hepatopetal flow. The common bile duct is normal measuring 5
mm. Single
views of both kidneys are normal bilaterally measuring 10 cm on
the right and 10.8 cm on the left without hydronephrosis.
Spleen is normal measuring 11.4 cm. The pancreas is normal.
The aorta and IVC are normal in their limited evaluation. There
is no free fluid.
IMPRESSION: Normal study without gallstones.
RENAL U/S ___:
FINDINGS: The right kidney measures 10.8 cm, and the left
kidney measures
10.8 cm.
There is no hydronephrosis, focal lesions, or nephrolithiasis
bilaterally.
The urinary bladder was distended, without evidence of bowel
wall thickening or any other abnormality. Some debris is noted
within the urinary bladder.
The pre-void volume is approximately 500 cc. The patient
declined voiding
hence assessment of post-void residual volume could not be made.
IMPRESSION: No evidence of hydronephrosis or any other renal
abnormality. Urinary bladder pre-void volume of approximately
500 cc.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Darunavir 600 mg PO BID
2. RiTONAvir 100 mg PO BID
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Aripiprazole 30 mg PO DAILY
5. Benztropine Mesylate 2 mg PO DAILY
6. Estrogens Conjugated 1.25 mg PO DAILY
7. Paroxetine 20 mg PO DAILY
8. OLANZapine 30 mg PO DAILY
Discharge Medications:
1. Darunavir 600 mg PO BID
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. RiTONAvir 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Kidney Injury, Acute hepatitis
Secondary: HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Transaminitis and nausea vomiting, assess for cholelithiasis or
cholecystitis.
COMPARISON: None.
FINDINGS: The liver is normal in echotexture without focal lesion, intra or
extrahepatic biliary ductal dilatation. The portal vein is patent with
hepatopetal flow. The common bile duct is normal measuring 5 mm. Single
views of both kidneys are normal bilaterally measuring 10 cm on the right and
10.8 cm on the left without hydronephrosis. Spleen is normal measuring 11.4
cm. The pancreas is normal. The aorta and IVC are normal in their limited
evaluation. There is no free fluid.
IMPRESSION: Normal study without gallstones.
Radiology Report
INDICATION: ___ female with acute renal failure and post-void
residual volume of 430 cc, concerning for urinary retention. Evaluate for
evidence of hydronephrosis or intrinsic renal disease.
COMPARISON: Limited views of the kidneys obtained in liver ultrasound on
___.
TECHNIQUE: Grayscale and color Doppler images of the kidneys and urinary
bladder were obtained.
FINDINGS: The right kidney measures 10.8 cm, and the left kidney measures
10.8 cm.
There is no hydronephrosis, focal lesions, or nephrolithiasis bilaterally.
The urinary bladder was distended, without evidence of bowel wall thickening
or any other abnormality. Some debris is noted within the urinary bladder.
The pre-void volume is approximately 500 cc. The patient declined voiding
hence assessment of post-void residual volume could not be made.
IMPRESSION: No evidence of hydronephrosis or any other renal abnormality.
Urinary bladder pre-void volume of approximately 500 cc.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABNORMAL LAB VALUES
Diagnosed with RENAL & URETERAL DIS NOS
temperature: 98.2
heartrate: 95.0
resprate: 16.0
o2sat: 96.0
sbp: 129.0
dbp: 95.0
level of pain: 0
level of acuity: 3.0 | ___ year-old M to F pre-op transgender w/ hx of HIV+ (last CD4
425 in ___ presents with 4 weeks of nausea/vomiting/abdominal
pain, found to have transaminitis and acute renal failure.
# Transaminitis: Patient presented with ALT/AST in the 200s.
These continued to down-trend throughout her admission. Her
synthetic function and biliary clearance remained intact. Her
viral serologies were negative for HAV/HCV infection, and
demonstrated HBV immunity. RUQ U/S was unrevealing, and patient
demonstrated no evidence of cholestasis. Patient's transaminitis
was likely the result of a drug effect, particularly the
multiple prescription and non-prescription, estrogen-containing
compounds, including Premarin, "Bountiful Breast", and "Breast
Rx". These non-prescription supplements reportedly contained
bovine pituitary/ovarian extracts as well as other unknown
ingredients. On discharge, the patient was instructed to
discontinue all estrogen-containing supplements, as well as
other potentially hepatotoxic medications, including
aripiprazole, olanzapine, and paroxetine. While several
components of her HAART are potentially hepatotoxic, these were
not discontinued in the hope that discontinuation of her
estrogen supplements would lead to normalization of her LFTs,
thus avoiding any changes to her HIV regimen. Once LFTs resolve,
outpatient providers, including PCP and psychiatrist can decide
on re-introduction of potentially hepatotoxic psych meds.
# Acute renal failure: Although the differential here is broad,
the most likely explanation is volume depletion in the setting
of protracted vomiting. Supporting this hypothesis, the
patient's Creatine improved from 3.1 on admission to 2.2 with 2
days of aggressive hydration. Upon discharge, renal thought that
this creatinine may represent her new baseline. Patient may have
had a component of post-renal kidney injury given her FENa of
3.8%. This was substantiated by PVR of 430cc and subsequent
renal u/s showing 500cc in bladder. Although there was no
evidence of hydronephrosis, obstruction may have played some
role in patient's renal failure. Other PVRs were around 300cc.
She had been taking multiple estrogen-containing supplements,
which can cause prostatic enlargement and subsequent urinary
retention. As mentioned above, drug effects may have been
playing a role in her renal failure. As described under
#Transaminitis, multiple medications, particularly
estrogen-containing supplements were discontinued. Patient is
scheduled to follow-up with Dr. ___ of nephrology in
2 weeks time.
# Nausea/vomiting/Abdominal pain: Patient endorsed a strong
association with PO intake and her GI symptoms, making
PUD/GERD/Gastritis high on the differential. Ranitidine 150mg
daily (renally dosed) was started on ___ and patient's GI
symptoms improved dramatically. She stated that she was able to
tolerate full meals for the first time in 4 weeks. She was
discharged on ranitidine with the presumptive diagnosis of GERD.
If she were to develop worsening symptoms or evidence of anemia,
EGD would be a reasonable next step in her evaluation.
# HIV+: CD4+ count was 319 on admission. Patient reports strict
adherence to her antiretroviral regimen. She was continued on
Truvada, ritonavir, and prestiza. If her transaminitis does not
fully resolve with the aforementioned subtractions from her
medication regimen, may need to consider adjusting HAART regimen
to minimize hepatotoxicity.
=
=
=
=
================================================================
TRANSITIONAL ISSUES
#Patient will need f/u LFTs and Creatinine check within a week
of discharge
#As her multiple estrogen-containing supplements are the most
likely culprits in her transaminitis, could consider
reintroducing potentially hepatotoxic psychiatric medications
once LFTs normalize. |
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 from 20 ft, +LOC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with PMH significant for HTN presenting s/p
fall approximately ___ feet off of deck, + LOC. Patient does
not remember falling. He does report the railing on his deck is
broken. Unable to recall if lightheadedness or dizziness prior.
+LOC. After falling he called out to his daughter who found him
on the ground. In the ED patient is not complaining of headache,
nausea or vision changes; patient complains of back pain.
Past Medical History:
PMH: B12 Deficiency, GERD, HLD, HTN, Non-Operative Type A
Thoracic Aortic Aneurysm 4.4 cm
PSH: Right Knee Surgery, Prostatectomy
Social History:
___
Family History:
Non-Contibutory
Physical Exam:
GEN: NAD, well appearing
HEENT: NCAT, PERRLA, EOMI, mid-face stable, no nystagmus as
noted previously, superficial abrasions per previous
NEURO: sensation and motor function grossly in tact throughout,
CN II-XII in tact
CV: RRR, radial pulses 2+ b/l
RESP: breathing comfortably
GI: soft, non-TTP, no R/G/D
EXT: limited ROM RUE, otherwise well perfused
Pertinent Results:
___ 05:25AM BLOOD WBC-9.2 RBC-4.67 Hgb-15.3 Hct-45.9 MCV-98
MCH-32.8* MCHC-33.3 RDW-13.2 RDWSD-47.9* Plt ___
___ 08:31PM BLOOD Neuts-60.0 ___ Monos-10.5 Eos-1.7
Baso-0.6 Im ___ AbsNeut-4.81 AbsLymp-2.09 AbsMono-0.84*
AbsEos-0.14 AbsBaso-0.05
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-100 UreaN-14 Creat-1.2 Na-139
K-4.1 Cl-98 HCO3-28 AnGap-17
___ 08:31PM BLOOD Glucose-131* UreaN-13 Creat-1.1 Na-137
K-3.9 Cl-102 HCO3-23 AnGap-16
___ 08:31PM BLOOD ALT-21 AST-37 AlkPhos-79 TotBili-0.3
___ 05:25AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.3
___ 08:31PM BLOOD Albumin-4.2
Medications on Admission:
1. ASA 81 mg PO daily
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN stool softener
RX *docusate sodium [Doc-Q-Lace] 100 mg 1 capsule(s) by mouth
twice a day Disp #*20 Capsule Refills:*0
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
9.Outpatient Physical Therapy
For Shoulder Pain
10.Outpatient Physical Therapy
For Vestibular ___ patient diagnosed with Benign Paroxysmal
Positional Vertigo
Discharge Disposition:
Home
Discharge Diagnosis:
Single non-displaced fracture of the right fifth rib.
Non-displaced right-sided mid thoracic transverse process
fractures involve the T7, T8, and T9 vertebral bodies
Sub-Arachnoid Hemorrhage
BPPV, Benign Paroxysmal Positional Vertigo
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 HEAD W/O CONTRAST
INDICATION: ___ with ___ ft fall, 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: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
Focal hyperdensity along the anterior falx, as well as appearing to
interdigitate within the cingulate sulcus on the right (series 2, image 17 as
well as series 601b, image 42) concerning for subarachnoid hemorrhage. There
is no evidence of hemorrhage elsewhere. There is no evidence of acute
infarction, edema, or mass. The ventricles and sulci are normal in size and
configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Small focus of subarachnoid hemorrhage along the medial right frontal lobe and
cingulate sulcus. No additional foci of hemorrhage identified.
NOTIFICATION: The findings were discussed with the surgical trauma team
members by ___, M.D. in person on ___ at 8:48 ___, 1
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with ___ ft fall with back pain, evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed through the
cervical spine. Soft tissue and bone algorithm images were generated. Coronal
and sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 829 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of fracture in the cervical spine. There is no
prevertebral fluid. The imaged cervical vertebral bodies are normally
aligned. Vertebral body heights are relatively preserved. There is at least
moderate multifactorial, multilevel cervical spine degenerative change, with
disc height loss most pronounced at C5-6. Mild spinal canal narrowing is most
pronounced at C5-6 due to posterior intervertebral osteophytosis (series 3,
image 47). Osteophytes may touch the very ventral surface of the spinal cord
at this level. There is no neural foraminal narrowing at any level.
Heterogeneous thyroid may represent small nodules, suboptimally assessed on
this study. There is no evidence of cervical lymphadenopathy. Lungs are
better evaluated on same-day CT chest.
IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Moderate multilevel cervical spine degenerative change, worst at C5-6 with
mild spinal canal narrowing this level due to intervertebral osteophytosis.
No neural foraminal narrowing.
Radiology Report
INDICATION: ___ with ___ ft fall, back pain, evaluate for evidence of
injury.
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: Total DLP (Body) = 1,381 mGy-cm.
COMPARISON: None available.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The ascending thoracic aorta aorta is demonstrates mild
fusiform dilation measuring up to 4.3 cm in diameter. The thoracic aorta is
otherwise unremarkable without evidence of intramural hematoma or dissection.
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: Aside from subsegmental relaxation atelectasis in the
dependent portions of the lower lobes, lungs clear without masses or areas of
parenchymal opacification. The airways are patent to the level of the
segmental bronchi bilaterally. Minimal scattered foci of background
centrilobular emphysema are noted.
BASE OF NECK: Hypodense thyroid nodules measure up to 5 mm in the left
thyroid lobe. Otherwise, the visualized portions of the base of the neck show
no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is focal fusiform
dilation of a right anterior intrahepatic bile duct branch (series 2, image
103). Otherwise, 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
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatus hernia. 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. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: Mild diffuse bladder wall thickening likely relates to
underdistention. The bladder is otherwise unremarkable. Surgical clips seen
in the expected location of the prostate likely reflect prior prostatectomy.
Surgical clips are also seen along the pelvic sidewall bilaterally. There is
no free fluid in the pelvis.
LYMPH NODES: Scattered retroperitoneal and mesenteric lymph nodes are not
technically pathologically enlarged by CT size criteria. There is no pelvic
or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: There are nondisplaced transverse process fractures on the right at T7,
T8 and T9 (series 2, image 83 and image 59). There is an equivocal right
nondisplaced transverse process fractures at T5 (series 2, image 39). There
is a nondisplaced fracture of the right posterolateral fifth rib (series 2,
image 47). No additional rib fractures are seen. The imaged thoracic and
lumbosacral vertebral bodies are normally aligned. Vertebral body heights are
preserved. No focal suspicious osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Single nondisplaced fracture of the right posterolateral fifth rib.
2. Nondisplaced right-sided mid thoracic transverse process fractures involve
the T7, T8, and T9 vertebral bodies, and possibly T5, as above.
3. No intrathoracic or intra-abdominal or intrapelvic solid or hollow viscus
organ injury identified.
4. Mild fusiform dilation of the ascending thoracic aorta measuring up to 4.4
cm in diameter. No acute aortic abnormality.
5. Small hiatus hernia.
6. Rectosigmoid diverticulosis.
7. Status post prostatectomy.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. in person on ___ at 9:04 ___, 1 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: TRAUMA #2 (AP CXR AND PELVIS PORT)
INDICATION: ___ with ___ ft fall. Back pain. // Trauma?
TECHNIQUE: Single supine view of the chest and single AP portable view of the
pelvis were obtained.
COMPARISON: CT torso from same date.
FINDINGS:
Chest: The cardiomediastinal silhouette and pulmonary vasculature are normal.
There is no pleural effusion or pneumothorax. There is no focal
consolidation. Posterior rib and transverse process fractures are better
evaluated on CT of the torso.
Pelvis: Multiple surgical clips are noted. There is no acute fracture.
Pubic symphysis and SI joints are preserved.
IMPRESSION:
No acute intrathoracic abnormality. No pelvic fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ s/p fall from 15 feet off deck, +HS, +LOC, SAH, R ___
posterolateral rib fx, T7, T9 (?also T5, T8) transverse process fx. Please
obtain at 6am ___. // Please obtain at 6am. eval evolution of ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 17.5 cm; CTDIvol = 51.2 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: CT head without contrast dated ___
FINDINGS:
Again seen is subtle subarachnoid hemorrhage around the anterior falx,
involving the cingulate sulcus on the right, most consistent with subarachnoid
hemorrhage. No new hemorrhage or worsening hemorrhage is identified. There
is no evidence of acute infarction, edema, or mass effect. The ventricles and
sulci are normal in size. The basilar cisterns are patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Stable subarachnoid hemorrhage from examination from 9 hours prior.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT
INDICATION: ___ year old man s/p fall // acute traumatic changes
TECHNIQUE: Three views right shoulder.
COMPARISON: CT chest abdomen and pelvis ___.
FINDINGS:
There are moderate degenerative changes at the acromioclavicular joint with
inferior spurring which may predispose to impingement. No fracture or
dislocation seen. No destructive lytic or sclerotic bone lesion. No
radiopaque foreign body or soft tissue calcification. Visualized portions of
the right lung are grossly clear.
IMPRESSION:
Degenerative changes at the acromioclavicular joint. No acute bony injury
seen.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Other fall from one level to another, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 7
level of acuity: 1.0 | Mr. ___ was admitted to the hospital following workup of his
fall. Following initial evaluation in the ED, the patient
received CT imaging which diagnosed a SAH in the right frontal
lobe. Consulting neurosurgery service recommended a repeat CT
image which demonstrated a stable SAH. They recommended against
anti-epileptic prophylaxis and plan to follow up with the
patient in the ___ as needed. In addition to
his head injuries, he also suffered multiple fractures in his
thoracic spine and a right sided rib fracture. These injuries
were deemed stable and did not require additional treatment.
He was complaining of right sided shoulder pain following a
formal XRay which demonstrated no acute bony changes. While
working with physical therapy, the patient was noted to be
unsteady on his feet and was subsequently diagnosed with BPPV.
The patient remained stable throughout his hospital admission
and received frequent neurological checks. He remained
neurologically in tact and appropriate throughout. He was
discharged and encouraged to follow up with his PCP and the
___ Clinic per Neurosurgery. He has no need to follow up
with ACS for his rib injury. He will receive ___ as an outpatient
for his shoulder and vestibular ___ for his BPPV. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with a history of HBV,
hemochromatosis, dCHF (LVEF > 55%), OSA on CPAP who presented
from home after receiving the result that his cardiac CT
performed one day prior to this evaluation showed an apical
pseudoaneurysm. Per medical records and per the patient, he has
experienced intermittent non-exertional left sided chest
pressure in setting of cardiac medication adjustments recently,
that led to the CT. He denies any ongoing chest pain or
shortness of breath though he is admittedly anxious about the
result and subsequently work-up, including this admission and
possible cath tomorrow.
In the ED, initial vital signs were: 96.6 72 130/76 17 99% RA.
Labs were notable for: WBC 11.7, INR of 2.6, UA negative, Cr of
1.0, Trop <0.01. Imaging with CXR showed no acute
cardiopulmonary process. Cardiac Surgery saw the patient and
deferred any surgical intervention at this point but recommended
Cardiology work-up of cardiac pathology, including possible
ischemia. Cardiology recommended admission to the ___ service,
2.5mg IV Vitamin K, administration of additional beta-blockade
to keep HR around 55-65, hold warfarin and keep NPO for possible
cath. Also recommended formal TTE. Vitals prior to transfer
were: 97.3 62 145/97 15 96% RA
Upon arrival to the floor, he reports the history above. He is
concerned and anxious about this admission but remains chest
pain free at present and denies dyspnea.
REVIEW OF SYSTEMS: Per HPI, reports episode of chest pain
earlier, denies ongoing pain. Also complains of constipation.
Also denies headache, visual changes, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea or lower extremity
swelling.
Past Medical History:
- Hemochromatosis (Negative Cardiac MR)
- Chronic HBV
- Hx of DVT (after motorcycle accident)
- Secondary polycythemia (Requires Phlebotomy)
- OSA on CPAP
- Asthma
- Migraines
- Atrial Fibrillation
- Hypertension
Social History:
___
Family History:
Patient has a family history of cardiovascular disease.
Physical Exam:
ADMISSION EXAM
==============
VITALS: 98.2F 128/57 83 18 97%RA
GENERAL: well-appearing, in no apparent distress.
HEENT: NC/AT, no scleral icterus, PERRLA, EOMI
NECK: supple, no LAD
CARDIAC: irregularly irregular, no murmurs appreciated
PULMONARY: clear to auscultation, no wheezes appreciated
ABDOMEN:soft, non-tender, non-distended
EXTREMITIES: warm, well-perfused, no edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
DISCHARGE EXAM
==============
VS: T98.2 91-119/60-64 ___ 95-97%RA
GENERAL: appearing anxious and very flat affect, but
appropriate
HEENT: NC/AT, no scleral icterus, PERRL, EOMI
NECK: supple
CARDIAC: irregularly irregular, no murmurs appreciated
PULMONARY: clear to auscultation, no wheezes appreciated
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: warm, well-perfused, no edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 06:50PM BLOOD WBC-11.7* RBC-4.84 Hgb-16.0 Hct-44.5
MCV-92 MCH-33.1* MCHC-36.0 RDW-12.4 RDWSD-41.9 Plt ___
___ 06:50PM BLOOD Plt ___
___ 11:45PM BLOOD ___ PTT-52.2* ___
___ 06:50PM BLOOD Glucose-141* UreaN-18 Creat-1.0 Na-138
K-3.2* Cl-98 HCO3-27 AnGap-16
___ 06:50PM BLOOD cTropnT-<0.01
IMAGING
=======
___ CARDIAC STRUCTURE/MORPH, 3D
EXTRACARDIAC FINDINGS: No mediastinal or hilar
lymphadenopathy. The imaged central airways are
patent. No evidence of pulmonary consolidation or mass. A
sub-2 mm calcified
pulmonary nodule is seen in the left lower lobe (10:21),
consistent with a
granuloma. No concerning pulmonary nodules are identified. The
included
portion the upper abdomen is grossly unremarkable. No
concerning lytic or
sclerotic lesions are seen within the imaged osseous structures.
IMPRESSION:
1. 1.5 cm pseudoaneurysm originating at left ventricular
apex.
2. Abnormal coronary CTA with mild stenosis of the mid LAD
and proximal RCA, as described above.
3. Minimal coronary artery calcifications. Agoston score will
be updated and an addendum will be issued once reformats are
completed.
4. Mild left ventricular hypertrophy and dilatation of the
left atrium.
___ Cardiac MRI: At time of this discharge summary writing,
only the extracardiac reportings were finalized
RECOMMENDATION(S):
1. Cholelithiasis.
2. Stable 5 mm cystic lesion in the uncinate process of the
pancreas.
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-10.6* RBC-4.67 Hgb-15.5 Hct-42.7
MCV-91 MCH-33.2* MCHC-36.3 RDW-12.4 RDWSD-40.8 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD ___ PTT-46.6* ___
___ 03:10PM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-138
K-3.7 Cl-100 HCO___-26 AnGap-16
___ 06:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:10PM BLOOD Calcium-10.2 Phos-2.3* Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 250 mg PO QHS
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Gemfibrozil 600 mg PO DAILY
7. LamoTRIgine 150 mg PO QHS
8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
9. Warfarin 4 mg PO 2X/WEEK (WE,SA)
10. Doxazosin 2 mg PO HS
11. ClonazePAM 0.5 mg PO QHS:PRN insomnia
12. Warfarin 2 mg PO 5X/WEEK (___)
Discharge Medications:
1. AcetaZOLamide 250 mg PO QHS
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
3. ClonazePAM 0.5 mg PO QHS:PRN insomnia
4. Doxazosin 2 mg PO HS
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Gemfibrozil 600 mg PO DAILY
7. LamoTRIgine 150 mg PO QHS
8. Lisinopril 10 mg PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Warfarin 2 mg PO 5X/WEEK (___)
12. Warfarin 4 mg PO 2X/WEEK (WE,SA)
Discharge Disposition:
Home
Discharge Diagnosis:
Stable apical aneurysm
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CARDIAC STRUCTURE/MORPH, 3D, FUNCTION
INDICATION: ___ year old man with borderline changes on a stress echo. Please
evaluate for obstructive cad. Cath ___ years ago was normal. // is there
obstructive coronary artery disease.
TECHNIQUE: 320-slice multidetector CT angiogram of the coronary arteries was
obtained using prospectiveECG gating with 100cc Omnipaque contrast
administered intravenously. To provide better evaluation of the anatomy and
disease process, advanced 3D post-processing techniques, including multiplanar
reconstruction, maximal intensity projections, curved reconstructions, and
volume rendering were performed on a separate workstation.
Medications: Nitroglycerine 0.4 mg PO x 1 dose
Vital Signs: The patient's heart rate was continuously monitored by a nurse.
Prior to this study, the heart rate was 58 beats per min and the blood
pressure was 121/75 mm Hg. Upon discharge, the heart rate was 68 beats per
min and the blood pressure was 104/70 mm Hg.
Procedure complications/allergic reactions: none
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.4 s, 16.0 cm; CTDIvol = 11.0 mGy (Body) DLP =
175.2 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 4.0 mGy (Body) DLP = 0.8
mGy-cm.
3) Stationary Acquisition 12.7 s, 0.2 cm; CTDIvol = 189.1 mGy (Body) DLP =
37.8 mGy-cm.
4) Stationary Acquisition 0.5 s, 12.0 cm; CTDIvol = 20.7 mGy (Body) DLP =
248.3 mGy-cm.
Total DLP (Body) = 462 mGy-cm.
COMPARISON: Chest x-ray dated ___, and cardiac MRI dated ___
FINDINGS:
Image Quality: The overall quality of the CT angiographic examination is
good.
CORONARY CTA:
Stenoses are reported as maximum percentage diameter stenosis.
Stenosis grading is reported using the following scheme:
Normal: No stenosis
Mild: ___ stenosis
Moderate: 50-70% stenosis
Severe: >70% stenosis
Dominance of the coronary artery system: right with normal origins and course.
Left Main: The left main is a normalcaliber vessel which gives rise to the
LAD and circumflex arteries. The left main has no stenosis with noplaque.
Left Anterior Descending Artery: The proximal left anterior descending artery
and first diagonal branch have no stenosis with no plaque. The mid LAD has
mild (<50%) stenosis due to mixed plaque. The distal LAD, D2 and D3 branches
have no stenosis with no plaque.
Left Circumflex Artery: The left circumflex artery and its obtuse marginal
branches have no stenosis with no plaque.
Right Coronary Artery: The proximal right coronary artery has less than 30%
stenosis due to soft plaque. The mid-distal right coronary artery, acute
marginal, right posterior descending artery, and right posterolateral branches
have no stenosis with no plaque.
CARDIAC MORPHOLOGY: The right atrium is normal. The right ventricle is
normal. The left atrium is mildly dilated. There is a 1.5 x 1.5 cm left
ventricular apical pseudoaneurysm (12:19, 11:24, 8:271). The walls of the
left ventricle appear mildly thickened. The pericardium is normal and there
is no pericardial effusion. The aortic valve is tricuspid with normal
leaflets.
EXTRACARDIAC FINDINGS:
No mediastinal or hilar lymphadenopathy. The imaged central airways are
patent. No evidence of pulmonary consolidation or mass. A sub-2 mm calcified
pulmonary nodule is seen in the left lower lobe (10:21), consistent with a
granuloma. No concerning pulmonary nodules are identified. The included
portion the upper abdomen is grossly unremarkable. No concerning lytic or
sclerotic lesions are seen within the imaged osseous structures.
IMPRESSION:
1. 1.5 cm pseudoaneurysm originating at left ventricular apex.
2. Abnormal coronary CTA with mild stenosis of the mid LAD and proximal
RCA, as described above.
3. Minimal coronary artery calcifications. Agoston score will be updated and
an addendum will be issued once reformats are completed.
4. Mild left ventricular hypertrophy and dilatation of the left atrium.
NOTIFICATION: Impression point 1 was discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:45 AM, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man presenting with chest pain. Evaluate for acute
cardiopulmonary process (effusion, vascular congestion).
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Lung volumes are slightly low, but not appreciably changed from the prior
exam. No focal consolidation, overt edema, pleural effusion, or pneumothorax.
The mediastinum is not widened. The heart is top-normal in size, unchanged.
No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR CARDIAC
INDICATION: ___ year old man with a history of HBV, hemochromatosis, dCHF
(LVEF > 55%), OSA on CPAP who presented from home after receiving the result
that his cardiac CT performed one day prior to this evaluation showed an
apical pseudoaneurysm.
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: Cardiac CT ___ and abdominal MRI ___ and
___.
IMPRESSION:
Please note that this report only pertains to extracardiac findings.
There is cholelithiasis without evidence of acute cholecystitis. A 5 mm
cystic lesion in the uncinate process of the pancreas is stable dating back to
___.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
RECOMMENDATION(S):
1. Cholelithiasis.
2. Stable 5 mm cystic lesion in the uncinate process of the pancreas.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Abnormal CT
Diagnosed with Aneurysm of heart
temperature: 96.6
heartrate: 72.0
resprate: 17.0
o2sat: 99.0
sbp: 130.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ year old man with a history of HBV,
hemochromatosis, dCHF (LVEF > 55%), afib on warfarin, OSA on
CPAP who presented from home after receiving the result that his
cardiac CT performed one day prior to this evaluation showed a
potential apical pseudoaneurysm.
#CHEST PAIN WITH CT WITH POSSIBLE APICAL PSEUDOANEURYSM:
Patient has known apical aneurysm, seen on ___ cardiac MRI.
Patient presented with evidence of pseudoaneurysm on CT and
recent history of left-sided chest pain, though he remained
pain-free during his hospitalization. The cardiac surgery team
was consulted, and felt that no emergent surgical intervention
was needed prior to further evaluation. A cardiac MRI was
obtained on ___, which revealed a true aneurysm that is stable,
thus not requiring any further intervention. His chlorthalidone
was held during the admission to keep the patient normotensive.
He was continued on his home lisinopril. He remained
asymptomatic and hemodynamically stable throughout his stay.
# AFIB: Admission INR 2.6. His warfarin was held during the
admission, and he was given IV vitamin K 2.5 to reverse
anticoagulation for potential cardiac surgery. His warfarin
should be resumed at his normal scheduled dosing after
discharge. His discharge INR was 2.1. His goal is 2.0-3.0. As
for his rate, his Metoprolol was continued during this
admission.
#OSA: Continued home CPAP and Acetazolamide daily
#HBV: Continued home Truvada
#CAD: Continued Gemfibrozil
#ANXIETY: Continued home Clonazepam
#HOME MEDS: Continued Suboxone (started ___ for oxycodone
dependence, now off oxy. Rx'ed by Dr. ___ at
___ and Lamotrigine
TRANSITIONAL ISSUES
===================
- no changes in his medications were made
- Warfarin was held and IV vitamin K 2.5mg x1 was given during
this admission, and discharge INR was 2.1. Pt was asked to take
4mg on night of discharge, which was a ___ (normally takes
4mg on ___ and ___ and 2mg the other days), and then resume his
normal schedule from the day after
- Pt should follow up with his cardiologist Dr. ___
within a week of discharge
# CODE STATUS: FULL (presumed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Nausea/ILI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of mental retardation, DM2, epilepsy p/w with reduced
PO intake x10 days associated with emesis/spitting up food and
subjective fever to her mother's touch, now with 1.5 days of
cough, and elevated lactate.
Per report from pt's mother, pt was in her usual state of health
until 10 days ago. She started to eat less and was gagging on
food and having emesis at times. She has had poor PO intake
since then. She was putting her hands over her ears while
swallowing frequently and she noted that she may have had some
pus-like material dripping from her right ear. She reports pt
with some grabbing of ears chronically. She reports no choking
or coughing episodes though with eating. She reports subjective
fevers as well for this time period but she did not have a
working thermometer.
She reports pt developed a cough and "gurgly" breathing
yesterday. She reports no seizures. No change in urinary
pattern. No BS checks for about 10 days, she thinks the BS was
normal but can't remember. All behavior other than eating
changes are at baseline. She reports soft slimy stools that are
dark from iron supplementation but no real change. Pt attends a
day program regularly and mother is unsure if sick contacts
there. She reports no prior PNAs or UTIs. She reports pt eats
regular diet without issue.
In the ED, initial vitals: 98.3 107 147/65 20 100% ra
- Exam was limited but notable for a soft, abdomen, patient was
moaning.
- Labs notable for: Lactate 5.8, WBC 5, Hgb 10.9, Hct 31.8, Plt
436, Cr 1, Na 139, Cl 101, Bicarb 20, Gap of 18.
- Repeat lactate 3.7
- Imaging notable for: blunting of the posterior costophrenic
angles, potentially small effusions or atelectasis. The
cardiomediastinal silhouette is stable. No acute osseous
abnormalities identified
- Pt given: 2L NS
- Vitals prior to transfer: 98.9 95 140/86 18 99% RA
On arrival to the floor, pt's mother reports she looks improved.
Past Medical History:
1. Seizure disorder, on phenobarbital times many years. No
seizures ___ years.
2. Type 2 diabetes, on Glucophage times ___ years.
3. Mental retardation, baseline nonverbal.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals- 98.1, 149-153/71-85, 87-97, 20, 100% RA
General- short statue woman with cognitive delay, nonverbal,
sitting up in bed, in NAD
HEENT- MMM, poor dentition, pt does not allow exam of oropharynx
Neck- supple, no LAD appreciated
CV- RRR, no murmurs
Lungs- clear but pt does not participate in exam, wet/gurgly
breathing suggestive of pooled upper airway secretions, no resp
distress
Abdomen- soft, NT/ND
Ext- warm, well perfused, no edema
Neuro- moves all extremities, nonverbal, does not participate in
exam,
Pertinent Results:
___ 12:48PM BLOOD Lactate-5.8*
___ 07:48PM BLOOD Lactate-3.7*
___ 01:48PM BLOOD Lactate-1.8
___ 06:11AM BLOOD WBC-4.0 RBC-3.17* Hgb-9.2* Hct-26.4*
MCV-83 MCH-29.1 MCHC-34.9 RDW-12.6 Plt ___
___ 12:30PM BLOOD WBC-5.0 RBC-3.79* Hgb-10.9* Hct-31.8*
MCV-84 MCH-28.8 MCHC-34.3 RDW-12.4 Plt ___
___ 12:30PM BLOOD Neuts-64.2 ___ Monos-4.8 Eos-1.8
Baso-0.3
___ 06:11AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-140
K-4.3 Cl-108 HCO3-20* AnGap-16
___ 12:30PM BLOOD Glucose-101* UreaN-22* Creat-1.0 Na-139
K-4.3 Cl-101 HCO3-20* AnGap-22*
___ 12:30PM BLOOD ALT-19 AST-21 AlkPhos-94 TotBili-0.1
___ 06:11AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.2*
___ 12:30PM BLOOD Albumin-4.5
CXR ___
FINDINGS:
The lungs are clear without focal consolidation or edema. There
is blunting
of the posterior costophrenic angles, potentially small
effusions or
atelectasis. The cardiomediastinal silhouette is stable. No
acute osseous
abnormalities identified.
IMPRESSION:
Possible small bilateral pleural effusions. No other signs of
acute
cardiopulmonary process.
___ 09:55PM URINE Color-Straw Appear-Clear Sp ___
___ 09:55PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
___ 09:55PM URINE RBC-<1 WBC-9* Bacteri-MOD Yeast-NONE
Epi-0
___ 09:55PM URINE AmorphX-OCC
___ 09:55PM URINE Mucous-RARE
___ 06:11AM BLOOD WBC-4.0 RBC-3.17* Hgb-9.2* Hct-26.4*
MCV-83 MCH-29.1 MCHC-34.9 RDW-12.6 Plt ___
___ 12:30PM BLOOD Neuts-64.2 ___ Monos-4.8 Eos-1.8
Baso-0.3
___ 06:11AM BLOOD Plt ___
___ 06:11AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-140
K-4.3 Cl-108 HCO3-20* AnGap-16
___ 12:30PM BLOOD Glucose-101* UreaN-22* Creat-1.0 Na-139
K-4.3 Cl-101 HCO3-20* AnGap-22*
___ 12:30PM BLOOD ALT-19 AST-21 AlkPhos-94 TotBili-0.1
___ 06:11AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.2*
___ 12:48PM BLOOD Lactate-5.8*
___ 07:48PM BLOOD Lactate-3.7*
___ 01:48PM BLOOD Lactate-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO TID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. PHENobarbital 20 mg/5 mL oral 15mL in the morning and 30mL at
night
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ferrous Sulfate 325 mg PO TID
4. PHENobarbital 20 mg/5 mL oral 15mL in the morning and 30mL at
night
5. Vitamin D 1000 UNIT PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Elevated lactate secondary to reduced intake of food
Viral infection
Secondary diagnoses:
Diabetes mellitus type 2
Epilepsy
Mental retardation
Discharge Condition:
Non-verbal at baseline
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough, fever // pna?
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear without focal consolidation or edema. There is blunting
of the posterior costophrenic angles, potentially small effusions or
atelectasis. The cardiomediastinal silhouette is stable. No acute osseous
abnormalities identified.
IMPRESSION:
Possible small bilateral pleural effusions. No other signs of acute
cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Nausea, ILI
Diagnosed with FEVER, UNSPECIFIED
temperature: 98.3
heartrate: 107.0
resprate: 20.0
o2sat: 100.0
sbp: 147.0
dbp: 65.0
level of pain: 13
level of acuity: 3.0 | Ms. ___ is a ___ w/ PMH of mental retardation, DM2, epilepsy
p/w with reduced PO intake x10 days associated with
emesis/spitting up food and subjective fevers who presented with
1.5 days of cough, and elevated lactate. Her hospital course by
problem is as follows:
# Lactic acidosis: Pt. presented with a lactate of 5.8 in the ED
which improved to 3.7 after 2L IVF and further improved to 1.8
after 3.5L. She received 4L IVF total. She was tachycardic on
admission; this resolved after IVF. She had no hypotension, no
leukocytosis or obvious source of infection. It was felt that
her high lactate was most likely secondary to global
hypoperfusion in the setting of volume depletion from poor PO
intake x10 days. No additional treatment was required for her
lactic acidosis other than IV fluids.
# Subjective fevers/cough/poor PO intake: It was felt that the
most likely etiology of her fevers, cough and poor PO intake was
a viral illness, as several other people at her day program have
recently been sick. The patient had no leukocytosis or fevers
and looked nontoxic, satting well on RA. She was noted to have a
small pleural effusion, but no PNA was read on CXR. An SLP
evaluation was ordered that showed no evidence of aspiration.
She had a U/A with +leuks, mod bacteria, 9 WBCS; she had a
similar U/A in ___ that grew a positive UCx. She also had a
history of otitis media/externa in ___ and per report was
manipulating her ears more frequently than usual in the past
week. She had no other clear source of infection to explain
potential subjective fevers. Blood cultures and urine cultures
were taken that were pending at time of discharge.
# Right ear drainage: The patient has a significant cerumen
burden in the right ear that was felt to be the most likely
etiology of the right ear drainage, which is an ongoing, chronic
problem with no acute worsening. The patient's family was
advised to provide her with over-the-counter debrox/hydrogen
peroxide ear drops and to follow-up with their primary care
doctor for ___ repeat otoscopic examination, as visualization of
the right TM was not possible.
# Hypomagnesemia: 1.2, in setting of poor PO intake. Repleted
with 2mg IV magnesium.
# T2DM: Patient received sliding scale insulin.
# Epilepsy: Continued home phenobarbital
# Chronic anemia: Continued iron supplements
********TRANSITIONAL ISSUES:****************
# Needs follow-up otoscopic exam of right ear after cerumen is
dissolved
# Consider drawing follow-up lactate if concern for ongoing poor
PO intake |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___- laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a ___ year old woman who presented to the ___ ED
with a six day history of right upper quadrant and epigastric
pain. The pain started last ___, and worsened progressively.
The pain was intermittent, worsened with eating, and was
associated with nausea and chills but no emesis. Pain was ___
before coming to the ED, and was ___ in the ED. Patient had
diarrhea last ___ and ___ and also the morning of
presentation. Patient denied alcohol use, fever, jaundice, pale
stools, change in urine color, or similar pain in the past.
Past Medical History:
Reports an unclear abdominal surgery in the ___.
Social History:
___
Family History:
Mother has a history of leukemia, father is healthy. She has a
___ sister, ___ brother. She has three
children.
Physical Exam:
GEN: NAD, A&Ox3
RESP: CTAB
___: RRR
ABD: Patient has moderate appropriate post-operative abdominal
pain located mostly in RUQ and right flank
Pertinent Results:
___ 06:10PM URINE HOURS-RANDOM
___ 06:10PM URINE HOURS-RANDOM
___ 06:10PM URINE UCG-NEGATIVE
___ 06:10PM URINE GR HOLD-HOLD
___ 06:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:30PM GLUCOSE-80 UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-9
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:30PM estGFR-Using this
___ 02:30PM ALT(SGPT)-33 AST(SGOT)-36 ALK PHOS-60 TOT
BILI-0.4
___ 02:30PM LIPASE-54
___ 02:30PM ALBUMIN-4.3
___ 02:30PM WBC-8.6 RBC-4.43 HGB-10.5* HCT-34.3* MCV-77*
MCH-23.7* MCHC-30.6* RDW-15.5
___ 02:30PM NEUTS-48.0* LYMPHS-46.0* MONOS-3.8 EOS-1.4
BASOS-0.7
___ 02:30PM PLT COUNT-499*
Radiology Report
INDICATION: Epigastric and right upper quadrant pain.
TECHNIQUE: Right upper quadrant ultrasound.
COMPARISON: Ultrasound dated ___ and CT dated ___.
FINDINGS: The liver is normal in echogenicity and contour. No focal liver
lesion is seen. The portal vein is patent with hepatopetal flow. No intra-
or extra-hepatic biliary dilation is seen. The CBD measures 4 mm. The
gallbladder contains several shadowing stones. No wall thickening or
pericholecystic fluid is seen. The gallbladder remains nondistended. No free
fluid is identified. Limited views of the pancreas are unremarkable, though
the distal body and tail are not visualized due to overlying bowel gas.
IMPRESSION: Cholelithiasis without specific signs of acute cholecystitis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: UPPER ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.6
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 102.0
dbp: 63.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ initially presented to the emergency department with
a six day history of RUQ pain; an ultrasound demonstrated
gallstones and she was diagnosed with acute cholecystitis. She
was given one dose of unasyn in the ED and developed throat
swelling, dyspnea, and chest pain. She was treated with an
epipen, benadryl, and solumedrol in the ER with symptomatic
relief. Her symptoms had nearly resolved in the ED however she
was admitted overnight to the ICU for close monitoring. She had
no further respiratory issues overnight, and was taken on HD 2
to the OR for laparoscopic cholecystectomy. For full details
please see the dictated operative report.
She tolerated the procedure well and was taken to the floor for
further care. Postoperatively, she did well. She tolerated her
PO's, and did not have any nausea/vomiting, had significantly
reduced abdominal pain, and felt better.
She was discharged on HD3, POD2, with the following discharge
instructions: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine / Talwin / Percocet
Attending: ___.
Chief Complaint:
blurry vision, headache, bilateral upper extremity shaking
Major Surgical or Invasive Procedure:
Diagnostic angiogram on ___
History of Present Illness:
patient is a ___ year old woman known to Dr ___ many
prior aneurysm interventions including clippings and coilings.
She has never had a reported rupture and was scheduled to
followup for a routine diagnostic angiogram in ___. Today
she was walking when she had a sudden onset of bilateral blurry
vision as well as severe eye pain left worse than right behind
her eye brows per her report. She also reports experiencing
bilateral upper extremity as well as torso shaking. She went to
an OSH where she was seen and evaluated and a Head CT was
performed without contrast to assess for intracranial
hemorrhage.
This was read as grossly negative as tere was a substantial
amount of coil and clip artifact on the scan. Her case was
discussed with Dr ___ recommended transfer to ___ for
further evaluation. Upon arriving here she endorses photophobia,
blurry vision, and eye pain. All three of these symptoms have
improved since she was at the OSH. She denies changes in hearing
or speech, changes in bowel or bladder function, or changes in
ability to ambulate.
Past Medical History:
multiple intracranial aneurysm s/p clippings and coilings,
kidney stones, CVA
Social History:
___
Family History:
multiple family members who passed away from
intracranial aneurysms
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, 4mm to
2mm bilaterally. Visual fields are grossly 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: L grip ___, bi/tri 4+, delt 5-. RUE, BLE full ___. Normal
bulk and tone bilaterally. LUE slightly tremulous on pronator
drift exam however has No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger bilaterally
Exam on Dishchrge:
she was A&Ox3, PEERL, EOMI
No drift, face symmetrical
MAE ___
Dressing to L groin cd&i, no hematoma or oozing
Bilateral pedal pulses 3+
Pertinent Results:
___ Outside hospital HCT was negative for acute
intracranial processes.
___ Diagnostic angiogram:
REad PND
Medications on Admission:
aggrenox, nadolol, lamictal, folic
acid, vitamin B2, amitriptyline
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Amitriptyline 10 mg PO DAILY
3. Famotidine 20 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. LaMOTrigine 75 mg PO BID
6. Nadolol 40 mg PO DAILY
7. Bisacodyl 10 mg PO/PR DAILY
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right MCA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ANGIO REPORT
DATE OF SERVICE: ___.
PREOPERATIVE DIAGNOSIS: Multiple aneurysms with sudden left retroorbital
headache and transient loss of vision.
ATTENDING: ___.
ASSISTANT: None.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intraservice time of 5 minutes during
which the patient's hemodynamic parameters were continuously monitored.
PROCEDURES PERFORMED: Right internal carotid artery arteriogram, right common
carotid artery arteriogram, left internal carotid artery arteriogram, left
vertebral artery arteriogram, left common femoral artery arteriogram and
Angio-Seal closure of left common femoral artery puncture site.
DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV
sedation was given. Following this, both groins were prepped and draped in a
sterile fashion. Multiple attempts were made to access the right common
femoral artery, this was unsuccessful. We now accessed the left common
femoral artery using a Seldinger technique and a 5 ___ vascular sheath was
placed in the left common femoral artery. We now catheterized the
above-mentioned vessels and AP, lateral filming was done. This revealed a 4
mm irregular aneurysm of the right middle cerebral artery. We now did a left
common femoral artery arteriogram and a 6 ___ Angio-Seal was used for
closure of the left common femoral artery puncture site.
FINDINGS: Right internal carotid artery arteriogram shows filling of the
right internal carotid artery along the cervical, petrous, cavernous and
supraclinoid portions. The anterior and middle cerebral arteries are seen
well. Though there are multiple coils and clips along the course of the
supraclinoid carotid artery, no aneurysms were found. There is a Neuroform
stent in the supraclinoid carotid artery without any stenosis. There is a 4
mm aneurysm of the middle cerebral artery at the origin of the anterior
temporal artery. This aneurysm is irregular and the anterior temporal branch
is incorporated into the aneurysm. The anterior cerebral artery is seen to be
dominant on the right side.
Right common carotid artery arteriogram shows no evidence of stenosis at the
carotid bifurcation.
Left internal carotid artery arteriogram shows filling of the left internal
carotid artery along the cervical, petrous, cavernous and supraclinoid
portions. The anterior and middle cerebral arteries are seen well. There is
significant stenosis at the origin of the left anterior cerebral artery;
however, there is good collateral flow from the right side.
There is a Neuroform stent in the left supraclinoid carotid artery extending
into the left middle cerebral artery. There is no evidence of stenosis at the
stent. Multiple aneurysms and coils are seen in this region; however, there
is no evidence of aneurysm formation. The left carotid bifurcation shows some
irregular atherosclerotic disease; however, there is no stenosis.
Left vertebral artery arteriogram shows filling of the left vertebral artery
with reflux into the right vertebral artery. Both PCAs are seen well with no
evidence of aneurysms or arteriovenous malformation.
Left common femoral artery arteriogram shows widely patent left common femoral
artery.
___ underwent cerebral angiography which revealed a 4 mm
aneurysm of the right middle cerebral artery incorporating the anterior
temporal branch at its base. There are multiple aneurysms, clips, coils and
bilateral Neuroform stents; however, no additional aneurysms were seen.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: HEADACHE
Diagnosed with HEADACHE
temperature: 98.2
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 96.0
dbp: 51.0
level of pain: 2
level of acuity: 2.0 | Ms. ___ was admitted to the intensive care unit on
___ for observation after presenting with symptoms concerning
for intracranial processes related to her past coilings. On
___, she remained stable waiting for a diagnostic angiogram. A
diagnostic angiogram was completed by Dr. ___ showed that
she had right MCA aneurysm but will come back to electively for
treatment. The patient remained neurologically and
hemodynamically stable and was discharged home in stable
conditions in the morning of ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Percocet / vancomycin / midazolam
Attending: ___.
Chief Complaint:
Vomiting, extension of aortic dissection, frozen shoulder
Major Surgical or Invasive Procedure:
Closed reduction of right shoulder dislocation (___)
History of Present Illness:
Mr. ___ is a ___ with PMH including HTN, CAD, HOCM,
AFib on Coumadin s/p pacemaker, mechanical AVR with aortic root
repair with 2 recent hospitalizations at ___ for aortic
dissection ___, and subsequently extension of aortic
dissection with decreased perfusion to L kidney (discharged
___, now re-presenting with extension of aortic dissection, as
well as R "frozen shoulder".
Pt reports that on ___ evening he began vomiting at his
assisted living facility. Vomited several times overnight. He
spoke with his PCP the next morning, who advised him to go to
the ED. He presented to the ED at ___, where CT was performed
that showed extension of his dissection from carotid to iliac.
At this point he was sent to ___ for further management.
In addition, pt reports that for the past 3 weeks, his should
has been "frozen". Pushed himself up out of bed and felt it go
out of place. Reportedly saw orthopedics 1 week ago, but was
told he could not undergo any intervention because of his other
current health issues.
Of note, pt has not experienced any vomiting since early ___
morning. He is not sure whether his blood pressures were
adequately controlled at his assisted living facility. Denies
CP/SOB/n/v/f/c/d.
In the ED, initial VS were 99.0 70 118/61 16 97% RA
Exam notable for R shoulder pain with limited ROM.
Labs were notable for:
___:
INR 2.9, Hgb 11.9, Plts 140, Creat 0.6, Trop T<.01 x 2
UA: unremarkable
___:
INR 3.4, Hgb 12.3, K 3.3
Received:
___ 23:12 PO/NG Atorvastatin 80 mg
___ 23:12 PO/NG Allopurinol ___ mg
___ 23:15 PO HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB
___ 08:32 IVF NS ___ Started 150 mL/hr
___ 14:07 IVF NS ___ Confirmed No Change in
Rate, rate continued at 150 mL/hr
___ 17:06 IVF NS Stopped (8h ___
Transfer VS were 70 112/50 18 99% RA
Orthopedics and vascular were consulted. Both agreed on
admission to medicine for further management of blood pressure,
R frozen shoulder.
On arrival to the floor, patient was in NAD. Reports R shoulder
pain, but otherwise no complaints.
Past Medical History:
HTN
HLD
HOCM
Depression
CAD
Osteoporosis
BPH
Afib s/p multiple electrical cardioversions
Spinal arthritis
Gout
Thyroid nodule
Varicose veins
Surgical History:
S/P ascending aortic aneurysm repair, aortic root replacement
and mechanical AVR ___, ___
Cardiac pacer placement ___, ___
UHR
L IHR
tonsils
Social History:
___
Family History:
AAA in both parents
DM2 in Mother
"Heart problems" in Father
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: 97.6 PO 112 / 66 72 18 95 Ra
GENERAL: Pleasant gentleman in NAD, resting comfortably,
somewhat of a poor historian
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, Mechanical S2 with soft systolic murmur heard
throughout precordium
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No edema, +varicose veins bilaterally, unable to
palpate dorsalis pedis pulses but able to palpate posterior
tibial pulses bilaterally, feet cool to touch, +onychomycosis; R
arm with very limited ROM, cannot lift past 30 degrees
NEURO: CN II-XII intact
SKIN: no excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
VS: 97.5 98/45 71 18 95%RA
GENERAL: Pleasant gentleman in NAD, sitting up on edge of bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, Mechanical S2 with soft systolic murmur heard
throughout precordium
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in RLQ, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No edema, +varicose veins bilaterally, unable to
palpate dorsalis pedis pulses but able to palpate posterior
tibial pulses bilaterally, feet cool to touch, +onychomycosis; R
arm with very limited ROM, cannot lift past 30 degrees
NEURO: CN II-XII intact
SKIN: no excoriations or lesions, no rashes
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:08PM BLOOD WBC-7.1 RBC-3.99* Hgb-11.9* Hct-36.6*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.8 RDWSD-47.2* Plt ___
___ 06:08PM BLOOD Neuts-83.7* Lymphs-7.1* Monos-6.2 Eos-2.4
Baso-0.3 Im ___ AbsNeut-5.94# AbsLymp-0.50* AbsMono-0.44
AbsEos-0.17 AbsBaso-0.02
___ 06:08PM BLOOD ___ PTT-40.9* ___
___ 06:08PM BLOOD Glucose-92 UreaN-24* Creat-0.6 Na-137
K-3.6 Cl-103 HCO3-21* AnGap-17
___ 06:08PM BLOOD cTropnT-<0.01
___ 03:50AM BLOOD cTropnT-<0.01
==============
DISCHARGE LABS
==============
___ 06:26AM BLOOD WBC-4.0 RBC-3.75* Hgb-11.3* Hct-34.9*
MCV-93 MCH-30.1 MCHC-32.4 RDW-13.8 RDWSD-46.8* Plt ___
___ 06:26AM BLOOD Glucose-91 UreaN-22* Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
==============
INR TREND
==============
___ 06:26AM BLOOD ___ PTT-42.1* ___
___ 09:50AM BLOOD ___ PTT-52.9* ___
___ 06:15AM BLOOD ___ PTT-41.1* ___
___ 06:45AM BLOOD ___ PTT-46.9* ___
___ 10:24AM BLOOD ___ PTT-47.5* ___
___ 07:00AM BLOOD ___ PTT-46.9* ___
==============
MICROBIOLOGY
==============
___ Urine Culture: No Growth
================
IMAGING/STUDIES
================
___ Shoulder XR:
IMPRESSION:
Concern for subtle impaction along the medial aspect of the
right humeral head. Right humeral head appears high riding and
possibly laterally subluxed.
___ Renal Doppler:
IMPRESSION:
Color flow demonstrated throughout both kidneys with patent
right and left main renal arteries, as above. Symmetric size
kidneys measuring 12 cm.
___ CT Shoulder
IMPRESSION:
1. Posterior right humeral dislocation associated with impacted
fracture at the anteromedial aspect of the humeral head suggest
reverse ___ lesion. No fracture of the glenoid is noted.
2. Nondisplaced fracture line is also noted involving the
lesser tuberosity.
3. Hyperdense foci along the posterior aspect of the glenoid
could represent dystrophic calcification, callus formation or
less likely hemorrhage.
___ TTE
The left atrial volume index is severely increased. The right
atrium is moderately dilated. There is severe asymmetric left
ventricular hypertrophy. The apex is relatively thin-walled but
not aneurysmal or hypokinetic. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF = 65%). The right ventricular free wall is hypertrophied.
with normal free wall contractility. The diameters of aorta at
the sinus, ascending and arch levels are normal. A bileaflet
aortic valve prosthesis is present. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
no major change is evident.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Allopurinol ___ mg PO QHS
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Carvedilol 50 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Calcium+D (calcium carbonate-vitamin D3) 250 - 150 mg oral
DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Isosorbide Dinitrate 10 mg PO TID:PRN for SBP>120
11. Blood Pressure Cuff (miscellaneous medical supply) 1 cuff
miscellaneous ONCE
12. Warfarin 4 mg PO DAILY16
13. Enoxaparin Sodium 75 mg SC PRN INR < 2.5
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: IV for breakthrough only
This medication should be discontinued once patient completes
___.
2. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN BREAKTHROUGH
PAIN
This medicine should be given prior to working with physical
therapy.
3. Isosorbide Dinitrate 10 mg PO TID:PRN for SBP>120
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
5. Polyethylene Glycol 17 g PO BID
6. Senna 17.2 mg PO HS
7. Acetaminophen 1000 mg PO Q8H
8. amLODIPine 5 mg PO DAILY
9. Enoxaparin Sodium 70 mg SC Q12H:PRN INR < 2.5
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Warfarin 2.5 mg PO DAILY16
11. Allopurinol ___ mg PO QHS
12. Atorvastatin 80 mg PO QPM
13. Blood Pressure Cuff (miscellaneous medical supply) 1 cuff
miscellaneous ONCE
14. Calcium+D (calcium carbonate-vitamin D3) 250 - 150 mg oral
DAILY
15. Carvedilol 50 mg PO BID
16. Docusate Sodium 100 mg PO BID
17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Extension of known aortic dissection, R
shoulder subluxation
Secondary Diagnoses: Mechanical AVR, atrial fibrillation, gout,
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US RENAL ARTERY DOPPLER
INDICATION: ___ yM the patient with AA with dissection and aortic valve
replacement found to propagation of dissection from carotid to iliac.// Please
do BOTH. ****BILATERAL RENAL ultrasound with doppler
TECHNIQUE: Grey scale, color and Doppler ultrasound images of the kidneys
were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 12.0 cm. The left kidney measures 12.1 cm. In the
upper pole of the left kidney, there is a 2.6 x 2.3 x 2.2 cm simple appearing
cyst. There is no sonographically evident hydronephrosis, stones, or solid
masses bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
Color flow was demonstrated throughout both kidneys. Both the right and left
renal arteries are patent with normal waveforms and continuous antegrade
diastolic flow. Resistive index of the right main renal artery was 0.78 with
peak systolic velocity of 44 cm /second. Resistive index on the left main
renal artery was 0.75 with peak systolic velocity of 31 cm/second. The main
renal veins are patent bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Color flow demonstrated throughout both kidneys with patent right and left
main renal arteries, as above. Symmetric size kidneys measuring 12 cm.
Radiology Report
INDICATION: ___ w/reported right shoulder dislocation 2 weeks ago,
complaining of persistent right shoulder pain, please eval for fracture,
dislocation// ___ w/reported right shoulder dislocation 2 weeks ago,
complaining of persistent right shoulder pain, please eval for fracture,
dislocation
TECHNIQUE: Three views of the right shoulder
COMPARISON: None.
FINDINGS:
There appears be subtle impaction along the medial aspect of the right humeral
head without displaced fracture seen. The right humeral head appears slightly
high riding and possibly laterally subluxed in relation to the glenoid. The
right acromioclavicular joint is intact.
IMPRESSION:
Concern for subtle impaction along the medial aspect of the right humeral
head. Right humeral head appears high riding and possibly laterally subluxed.
Radiology Report
EXAMINATION: CT of the right upper extremity.
INDICATION: ___ year old man with dislocated R shoulder// surgical planning
TECHNIQUE: Multidetector CT of the right shoulder was performed with coronal
and sagittal reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.3 s, 17.8 cm; CTDIvol = 25.0 mGy (Body) DLP = 425.2
mGy-cm.
2) Spiral Acquisition 2.7 s, 1.1 cm; CTDIvol = 24.9 mGy (Body) DLP = 10.3
mGy-cm.
3) Spiral Acquisition 4.0 s, 7.7 cm; CTDIvol = 24.9 mGy (Body) DLP = 152.2
mGy-cm.
Total DLP (Body) = 595 mGy-cm.
COMPARISON: Shoulder radiograph from ___.
FINDINGS:
The right humeral head is posteriorly dislocated with an impacted fracture
within the anteromedial aspect of the humeral head, suggesting reverse
___ lesion. No fracture of the glenoid is noted. A nondisplaced
fracture is also noted involving the lesser tuberosity. Hyperdense foci along
the posterior aspect of the glenoid could represent dystrophic calcification,
callus or less likely hemorrhage. Small glenohumeral effusion is noted.
There are mild hypertrophic changes in the acromioclavicular joint.
Thyroid nodules are better seen on prior chest CT.
IMPRESSION:
1. Posterior right humeral dislocation associated with impacted fracture at
the anteromedial aspect of the humeral head suggest reverse ___ lesion.
No fracture of the glenoid is noted.
2. Nondisplaced fracture line is also noted involving the lesser tuberosity.
3. Hyperdense foci along the posterior aspect of the glenoid could represent
dystrophic calcification, callus formation or less likely hemorrhage.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA IN O.R. RIGHT
INDICATION: Closed reduction
TECHNIQUE: 3 fluoroscopic images right shoulder
COMPARISON: ___
FINDINGS:
Images obtained for surgical purposes.
IMPRESSION:
Images obtained for surgical purposes
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Transfer
Diagnosed with Dissection of carotid artery
temperature: 99.0
heartrate: 70.0
resprate: 16.0
o2sat: 97.0
sbp: 118.0
dbp: 61.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ with PMH including HTN, CAD, HOCM,
AFib on Coumadin s/p pacemaker, mechanical AVR with aortic root
repair with 2 recent hospitalizations at ___ for aortic
dissection ___, and subsequently extension of aortic
dissection with decreased perfusion to L kidney (discharged
___, now re-presenting with extension of aortic dissection on
OSH CT, as well as R "frozen shoulder".
___ B Aortic Dissection: Pt experienced
multiple episodes of vomiting on ___, and after consulting with
PCP, was told to go to ED for evaluation. CT at OSH showed
extension of known aortic dissection from carotid to iliac.
While dissection has propagated, there is no evidence of
limitation of blood flow to ___ or visceral vessels aside from
known impairment to L kidney. Bilateral renal US wnl. In
consultation with vascular surgery service, decision was made to
persist with medical management for now. Strict blood pressure
goal of SBP <120 was continued. Due to one low BP reading while
inpatient that was associated with nausea, the patient's
amlodipine was reduced from 10mg to 5mg on ___. Since that
time, his blood pressure has remained within goal and he hasn't
experienced any episodes of nausea. Other anti-hypertensive
agents were not changed from pre-admission doses. Plan on
discharge was for follow up as outpatient with vascular surgery
for further management of his aortic dissection.
#R Shoulder Dislocation: Occurred 3 weeks before presentation
per pt. S/p XR in ED showing possible subluxation. Orthopedics
was consulted. CT shoulder showed a posterior right humeral
dislocation associated with impacted fracture at the
anteromedial aspect of the humeral head suggesting a reverse
___ lesion. There was also a non-displaced fracture line
noted to involve the lesser tuberosity. After obtaining
consensus pre-operative clearance from cardiology, cardiac
surgery, vascular surgery and anesthesia, on ___ he underwent a
closed reduction of right shoulder dislocation under
intra-articular block and MAC sedation. He will need to be
non-weight bearing in his right upper extremity x6 weeks
#Mechanical AVR: INR goal narrowed on recent admission to ___
as a result of bleeding risk from his dissection. Pt was
maintained on Warfarin while inpatient. He was bridged with
Lovenox at times when his INR dropped to < 2.5. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox /
Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide /
Minocycline / Cleocin / Percocet / vancomycin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH significant for recent admission for endocarditis
(pulmonic valve), dCHF, cirrhosis c/b variceal bleed, and AML
___ BMT who presented to ___ for dyspnea. Patient developed
throat and chest tightness, associated with shortness of breath.
She was reportedly very anxious with labored breathing. EMS was
activated. She was given albuterol nebs, SL nitro, ASA 325mg,
vicodine, and ativan with some relief of symptoms. She was
placed on O2 for comfort.
In the ED, initial vitals were: T97.6 P72 BP90/50 RR14 98% 2L.
Labs were notable for WBC 6.8, H/H 8.5/28.9, K 5.0, Cr 1.0. EKG
showed paced rhythm with RBBB. CXR showed stable bilateral
pleural effusions. The patient was given lasix 20mg IV, unknown
response. Vitals prior to transfer were: P70 BP107/73 RR18.
Upon arrival to the floor, patient reports progressive worsening
of dyspnea on exertion. She notes orthopnea, has used ___
pillows over past few months, weight gain, and increased
peripheral edema. She reports recurrent pleural effusions
secondary to her heart. The pleural effusions are drained
intermittently for symptoms. Last drainage was 3 months ago. She
does not like taking lasix or spironolactone as she already
makes several trips to the bathroom due to lactulose. No recent
fever, chills, cough, chest pain, palpitations, abdominal pain,
hematochezia, melena, or dysuria.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, and syncope or presyncope.
Past Medical History:
- Severe mitral stenosis (area < 1.0cm2) ___ MVR ___/b AMS, recurrent pleural effusions, pneumonia,
septic shock with bacteremia, and GI bleed due to varices
- Presumed diastolic dysfunction
- PEA arrest in ___. Husband resuscitated her. Found to be
in complete heart block ___ pace maker placement. Anoxic brain
damage with short term memory loss.
- Left breast cancer status post mastectomy with radiation
therapy in ___ and ___.
- AML - in CCR, ___ Cy/TBI conditioning and allogeneic T-cell
depleted allogeneic bone marrow transplant from sister in
___.
- BMT complicated by lymphoproliferative disorder status post
tonsillectomy and Rituxan in ___, ITP ___ Rituxan in ___
without recurrence, and hypogammaglobulinemia requiring monthly
IVIG.
- Basal cell carcinoma with excision in ___.
- Iron overload diagnosed by liver biopsy in ___ and
undergoing periodic phlebotomy
- cirrhosis due to hemachromatosis c/b varices, UGI bleed,
hepatic encephalopathy
- obstrucitve airway disease per PFTs
- recurrent pleural effusions ___ pleurX catheter (___), last
thoracentesis ___ (800cc drained)
Social History:
___
Family History:
Breast cancer in mother and sister.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T97.5 BP109/48 P78 RR20 100%3L Wt 55.9kg
General: Chronically ill appearing, sad affect, no acute
distress.
HEENT: Pupils equal and reactive to light. Oropharynx clear.
Neck: JVP at 8cm.
CV: RRR, normal S1, S2. ___ systolic murmur loudest at LLSB.
Lungs: Bibasilar crackles, L>R.
Abdomen: +BS, soft, nondistended, nontender to palpation.
GU: No foley.
Ext: Warm and well perfused. Pulses 2+. 1+ pitting edema up to
knees bilaterally.
Neuro: A+Ox3. Moves all extremities grossly.
Skin: No rash.
PHYSICAL EXAMINATION ON DISCHARGE:
VS: Weight 51.6 ___ yesterday, 55.9 on admit) BP 83-99/42-54 P
___ RR 18 94% RA
General: Elderly female, in NAD
HEENT: NC/AT, EOMI, sclera anicteric
Neck: JVP 2-3cm above clavicle at 45 degrees
CV: RRR, normal S1, S2. ___ systolic murmur loudest at LUSB.
Lungs: Mild bibasilar crackles. No w/r.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. Pulses 2+. Edema decreased from 2
days ago, currently trace-to-1+ edema to ankles.
Neuro: A+Ox3. moving all extremities, speech fluent.
Skin: No rash.
Pertinent Results:
LABS ON TRANSFER
___ 09:10AM BLOOD WBC-6.8 RBC-3.17* Hgb-8.5* Hct-28.9*
MCV-91 MCH-26.9* MCHC-29.5* RDW-18.2* Plt ___
___ 09:10AM BLOOD Neuts-79.2* Lymphs-9.0* Monos-9.6 Eos-1.8
Baso-0.5
___ 09:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+
Ovalocy-OCCASIONAL
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-107* UreaN-22* Creat-1.0 Na-137
K-5.0 Cl-104 HCO3-23 AnGap-15
___ 09:10AM BLOOD ALT-41* AST-56* AlkPhos-417* TotBili-0.5
___ 09:10AM BLOOD Lipase-46
___ 09:40AM BLOOD ___ 09:10AM BLOOD Albumin-3.6
___ 09:20AM BLOOD Lactate-1.3
LABS ON DISCHARGE
___ 06:00AM BLOOD WBC-6.7 RBC-3.07* Hgb-8.1* Hct-27.1*
MCV-88 MCH-26.4* MCHC-29.9* RDW-18.1* Plt ___
___ 09:30PM BLOOD Glucose-170* UreaN-29* Creat-1.2* Na-136
K-4.1 Cl-97 HCO3-28 AnGap-15
___ 09:30PM BLOOD Calcium-9.7 Phos-2.9 Mg-2.3
STUDIES
EKG ___ 9:11:36 AM
Atrial sensed, ventricularly paced rhythm. Underlying rhythm is
sinus rhythm. Compared to the previous tracing of ___ there
is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 ___ 51 -95 63
CXR ___
FINDINGS:
Compared with prior, there has been no significant interval
change. Right chest wall port and left chest wall dual lead
pacing device are again seen. Partially loculated right-sided
pleural effusion persists. Probable small left effusion is
partially loculated laterally. Right basilar opacities medially
may be due to atelectasis, similar to prior. The
cardiomediastinal silhouette is unchanged, mitral valve
prosthesis again noted. Surgical clips seen in the right upper
quadrant. No acute osseous abnormalities.
IMPRESSION:
No significant interval change. Bilateral effusions. Right
medial basilar opacity potentially atelectasis noting that
infection is not excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO HS:PRN PRN
4. Midodrine 10 mg PO TID
5. Rifaximin 550 mg PO BID
6. Sucralfate 1 gm PO QID
7. Phosphorus 500 mg PO DAILY
8. Potassium Chloride 20 mEq PO BID
9. Spironolactone 25 mg PO DAILY
10. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
11. Propranolol 20 mg PO TID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Gabapentin 100 mg PO HS
14. Aspirin EC 81 mg PO DAILY
15. Baclofen 5 mg PO BID
16. Furosemide 20 mg PO DAILY
17. Pantoprazole 40 mg PO Q12H
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
22. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
23. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
24. Senna 8.6 mg PO HS:PRN constipation
25. Milk of Magnesia 30 mL PO Q6H:PRN constipation
26. Fleet Enema ___AILY:PRN constipation
27. Bisacodyl ___AILY:PRN constipation
28. Lorazepam 0.25 mg PO BID:PRN anxiety
29. Acetaminophen 325-650 mg PO Q4H:PRN pain
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Aspirin EC 81 mg PO DAILY
3. Baclofen 5 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO BID
RX *furosemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Gabapentin 100 mg PO HS
7. Lactulose 30 mL PO HS:PRN PRN
8. Lorazepam 0.25 mg PO BID:PRN anxiety
9. Midodrine 10 mg PO TID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Propranolol 20 mg PO TID
13. Rifaximin 550 mg PO BID
14. Spironolactone 25 mg PO DAILY
15. Sucralfate 1 gm PO QID
16. Acetaminophen 325-650 mg PO Q4H:PRN pain
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
18. Bisacodyl ___AILY:PRN constipation
19. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
20. Fleet Enema ___AILY:PRN constipation
21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
23. Milk of Magnesia 30 mL PO Q6H:PRN constipation
24. Ondansetron 4 mg PO Q8H:PRN nausea
25. Phosphorus 500 mg PO DAILY
26. Potassium Chloride 20 mEq PO BID
Hold for K >
27. Senna 8.6 mg PO HS:PRN constipation
28. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
29. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart Failure, Diastolic Dysfunction vs Constrictive
Cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dyspnea // eval for pneumonia
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Compared with prior, there has been no significant interval change. Right
chest wall port and left chest wall dual lead pacing device are again seen.
Partially loculated right-sided pleural effusion persists. Probable small left
effusion is partially loculated laterally. Right basilar opacities medially
may be due to atelectasis, similar to prior. The cardiomediastinal silhouette
is unchanged, mitral valve prosthesis again noted. Surgical clips seen in the
right upper quadrant. No acute osseous abnormalities.
IMPRESSION:
No significant interval change. Bilateral effusions. Right medial basilar
opacity potentially atelectasis noting that infection is not excluded.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HX OF BREAST MALIGNANCY
temperature: 97.6
heartrate: 72.0
resprate: 14.0
o2sat: 98.0
sbp: 90.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | ___ with complicated medical history including recent
admission for variceal bleed and endocarditis, dCHF, and
cirrhosis of unknown etiology who presents due to CHF
exacerbated.
ACTIVE PROBLEM
# Heart Failure:
She was transferred on 3L O2 by NC, which was easily weaned.
Symptomatically she improved over the course of one day. Her
shortness of breath was believed to be due to heart failure due
to diastolic dysfunction vs restrictive cardiomyopathy (history
of hemachromatosis) given evidence of HF on history and exam
(med noncompliance, weight gain, orthopnea, increased ___ and
EF of >55% in ___. Her diuretic dose had been decreased
recently from Torsemide 40mg BID to Lasix 20mg daily and she
endorsed not having taken her diuretics as she already spent too
much time in the bathroom with the lactulose. She has recurrent
pleural effusions and is periodically drained by IP. They were
consulted and felt that her pleural effusions were stable from
the last time she was seen and drainage was not indicated at
this time and not likely to help symptoms. She was diuresed
with IV lasix with her weight decreasing from 55.9kg on admit to
51.7kg on discharge. She was discharged on lasix 40mg PO BID.
She is seen by Dr. ___.
# Vaginal Lesions:
Small, non-palpable dark purple pinpoint lesions (?purpura) seen
on inner labia, found incidentally when placing foley.
Asymptomatic, unclear etiology. Denies any recent sexual
activity. Follow up arranged with ___.
# Deconditioning:
Was admitted from rehab, where she was scheduled to be
discharged home on day of/day after admission. Seen by ___,
provided a walker with plan for home ___ services.
CHRONIC PROBLEMS
# Cirrhosis:
Cirrhosis secondary to hemochromatosis, complicated by
encephalopathy and variceal bleed. No history of SBP. ___
Classification A, MELD score 8. Patient currenly A+O, without
signs of encephalopathy. Home doses of propranalol, midodrine,
pantoprazole, lactulose, rifaxamin, and spironolactone were
continued.
# AML:
Pt is ___ transplant (___) c/b lymphoproliferative disorder,
ITP, and hypogammaglobulinemia. She receives monthly IVIG, last
on ___. Patient seen by Dr. ___. Anemic, borderline
thrombocytopenic-- both stable compared to last 3 months.
===================================================
TRANSITIONAL ISSUES
===================================================
Ms. ___ is a ___ yo woman with cirrhosis ___ hemochromatosis,
CHF, recent hospitalization for endocarditis (on pulmonic
valve), severe MR ___ MVR, h/o PEA arrest c/b heart block ___
PPM, AML ___ BMT who was admitted for CHF exacerbation.
[ ] Diuresis: From past records, it appears she was on torsemide
40mg BID in the past, but at her previous discharge was sent
home on lasix 20mg. Patient has GI upset with torsemide,
therefore we will discharge on lasix 40mg BID.
[ ] Chronic pleural effusion: Seen by IP for intermittent
drainage. IP did not feel she would benefit from thoracentesis
during hospitalization.
[ ] Vaginal lesions: Seen incidentally when placing a foley.
Appointment made with the ___ further
evaluation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
simvastatin / atorvastatin / lisinopril / Nexium
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
___ Plate of left distal femur fracture
History of Present Illness:
___ hx of AFib on Xarelto who sustained a mechanical fall
yesterday landing on her left leg. Patient denies headstrike,
loc, neck or back pain. She has sharp pain in the left distal
femur. She was taken to an OSH where on imaging head, C-spine,
and abdominal CT scans were negative for an acute process. She
had an xray of the left leg which demonstrated a comminuted left
distal femur fracture. She was transferred to ___.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: Atrial Fibrillation
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
diverticulosis
gerd
GI bleed ___
nephrolithiasis
Vitamin B12 deficiency
glaucoma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Exam on admission
Awake and alert, NAD
Left lower extremity:
- Skin intact leg in KI
- Thigh compartments soft
- Tenderness over distal femur
- No tenderness over knee or ankle. Plantar/dorsiflexion intact
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Exam on discharge
Awake and alert, NAD
LLE:
SILT ___ ___ +IP/Q
Foot WWP
Incision C/D/I. No erythema or edema
Pertinent Results:
___ 04:30AM BLOOD WBC-10.6* RBC-2.41* Hgb-8.3* Hct-25.2*
MCV-105* MCH-34.4* MCHC-32.9 RDW-13.4 RDWSD-51.8* Plt ___
Medications on Admission:
Xarelto 20 mg tablet oral
1 tablet(s) Once Daily
___ ___ 07:17)
omeprazole 40 mg capsule,delayed release oral
1 capsule,delayed ___ Once Daily
___ ___ 07:17)
lovastatin 40 mg tablet oral
1 tablet(s) Once Daily
___ ___ 07:17)
metoprolol succinate ER 25 mg tablet,extended release 24 hr
oral
0.5 tablet extended release 24 hr(s) Once Daily
___ ___ 07:18)
furosemide 40 mg tablet oral
1 tablet(s) Once Daily
___ ___ 07:18)
folic acid 1 mg tablet oral
1 tablet(s) Once Daily
___ ___ 07:18)
Vitamin B-12 1,000 mcg tablet oral
1 tablet(s) Once Daily
___ ___ 07:19)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 8 hours
Disp #*90 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth Every 8 hours Disp #*45
Tablet Refills:*0
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Every 8 hours
Disp #*45 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous injection Every
evening Disp #*30 Syringe Refills:*0
6. Furosemide 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*90
Tablet Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT LOW EXT W/O C LEFT
INDICATION: ___ woman with distal femur fracture, evaluate fracture
for preoperative planning.
TECHNIQUE: Contiguous axial multidetector CT images through the left knee
without contrast. Multiplanar reformations.
DLP: 1353 mGy-cm
COMPARISON: Left knee radiographs from ___
FINDINGS:
There is an acute comminuted fracture through the distal left femur, with
approximately 1 cm posterior displacement and medial angulation of the distal
fragment with respect to the proximal femoral shaft. There is also an
anterior apex angulation of the distal femur fracture. There is a 3 mm
intercondylar fracture fragment (404b:47). A 6 x 11 mm triangular fracture
fragment is also seen along the patellofemoral joint (403b: 66).
There is a small hemorrhagic effusion in the suprapatellar recess (03:21). A
small ___ cyst is also present with a hematocrit level and a very small
locule of fat on the anti dependent side (3:65).
IMPRESSION:
Posteriorly displaced medially angulated comminuted fracture of the distal
left femur as described above.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: ORIF LEFT FEMUR FX
TECHNIQUE: Screening provided the operating room without a radiologist
present. Total fluoroscopy time 59 seconds.
COMPARISON: ___ radiographs.
FINDINGS:
Images demonstrate fixation of distal femoral fracture, with lateral plate and
transverse interlocking screws. Alignment appears satisfactory. For details
of the procedure, please consult the procedure report.
IMPRESSION:
Operative images for fracture fixation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Femur fracture, Transfer
Diagnosed with FX LOW END FEMUR NOS-CL, UNSPECIFIED FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.8
heartrate: 92.0
resprate: 18.0
o2sat: 94.0
sbp: 146.0
dbp: 92.0
level of pain: 9
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 left distal femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ___ plate of L distal femur,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the left lower extremity with ___ brace in place,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal distention, confusion
Major Surgical or Invasive Procedure:
Paracentesis (___)
EGD (___)
History of Present Illness:
Ms. ___ is a ___ with Childs C alcoholic cirrhosis (MELD 15)
c/b hepatic encephalopathy, ascites who presents with 3 weeks of
worsening abdominal distention and lower extremity edema and
several days of confusion.
The patient sees Dr. ___ as an outpatient. Per patient's
sister in ___ notes, the patient has been getting more confused
over the last several days. The patient reports increased
abdominal distention and lower extremity swelling over the past
3 weeks. She indicates that she has been told that she has been
more confused over the past week but has not noticed many
changes in her mental status. When asked if she takes lactulose,
she believes she does but she indicates that her sister
administers her meds for her.
She denies any fevers, hematemesis, BRBPR, black tarry stools.
Past Medical History:
- EtOH cirrhosis (dx age ___
- Psoriasis (not on medication)
- Hypothyroidism
- Depression/anxiety
- Osteoporosis
- Insomnia
- Cholelithiasis (evidence on u/s)
Social History:
___
Family History:
Heavy alcohol abuse on her side of the family
- Father died when she was ___, etiology unknown
- Mother died at age ___ from ?COPD/emphysema
- Brother died for unknown reasons but related to etoh
- Sister has a cardiac history (valve replacement) and etoh
abuse
- Sister ___ is a nurse in the ___ at ___ - unclear ETOH
history
- Son has type I diabetes mellitus
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98, BP 170/72, HR 65, RR 16, O2 sat 96% RA
GENERAL: NAD, cooperative, calm
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: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: very distended, no fluid wave appreciated, mildly
tender in all four quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, 1+ pitting edema to knees bilatearlly
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, responding appropriately to questions, sensation
intact in bilateral upper and lower extremities, moving all 4
extremities with purpose, negative asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:47PM BLOOD WBC-5.4 RBC-3.73* Hgb-11.7 Hct-35.7
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.7* RDWSD-55.0* Plt ___
___ 01:47PM BLOOD Neuts-78.7* Lymphs-12.0* Monos-6.4
Eos-1.7 Baso-0.6 Im ___ AbsNeut-4.22 AbsLymp-0.64*
AbsMono-0.34 AbsEos-0.09 AbsBaso-0.03
___ 01:47PM BLOOD Glucose-82 UreaN-12 Creat-1.1 Na-139
K-3.7 Cl-100 HCO3-26 AnGap-13
___ 01:47PM BLOOD ALT-17 AST-47* AlkPhos-142* TotBili-1.9*
___ 01:47PM BLOOD Albumin-2.6* Calcium-8.3* Phos-2.5*
Mg-1.6
___ 06:59AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
STUDIES:
___ LIVER US: Cirrhotic liver with splenomegaly and large
volume ascites. The main portal vein is patent.
___ CHEST XRAY: Lung volumes are low. The lungs are clear
without focal consolidation. Cardiomediastinal and hilar
contours are normal. No evidence of pulmonary vascular
congestion. No pneumothorax or pleural effusion.
DISCHARGE LABS:
___ 05:23AM BLOOD WBC-5.2 RBC-3.08* Hgb-9.7* Hct-29.4*
MCV-96 MCH-31.5 MCHC-33.0 RDW-15.9* RDWSD-54.4* Plt Ct-76*
___ 05:23AM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-27 AnGap-10
___ 05:23AM BLOOD ALT-14 AST-36 AlkPhos-98 TotBili-1.2
___ 05:23AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.9 Mg-2.3
___ 05:11AM BLOOD CK-MB-<1 cTropnT-<0.01
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rifAXIMin 550 mg PO BID
2. Alendronate Sodium 35 mg PO 1X/WEEK (___)
3. FLUoxetine 40 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 300 mg PO QHS
6. Gabapentin 100 mg PO QAM
7. HydrOXYzine 25 mg PO BID:PRN itching
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Magnesium Oxide 400 mg PO BID
10. Nadolol 20 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Potassium Chloride 20 mEq PO EVERY OTHER DAY
13. Promethazine 25 mg PO BID:PRN nausea
14. Spironolactone 50 mg PO DAILY
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
17. Ferrous GLUCONATE 324 mg PO DAILY
18. Lactulose 30 mL PO QID
19. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q12H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*15 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*2
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
5. Alendronate Sodium 35 mg PO 1X/WEEK (___)
6. Ferrous GLUCONATE 324 mg PO DAILY
7. FLUoxetine 40 mg PO DAILY
8. Lactulose 30 mL PO QID
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Magnesium Oxide 400 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Hold for K >
14. rifAXIMin 550 mg PO BID
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
17. HELD- HydrOXYzine 25 mg PO BID:PRN itching This medication
was held. Do not restart HydrOXYzine until you talk to your PCP
18. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until you talk to your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
ASCITES
HEPATIC ENCEPHALOPATHY
CIRRHOSIS ___ ETOH
GAVE
SECONDARY DIAGNOSES
===================
DEPRESSION
HYPOTHYROIDISM
PERIPHERAL NEUROPATHY
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 cirrhosis p/w worsening ascitis// eval for portal
thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Prior ultrasound dated ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. There is no focal
liver mass. The main portal vein is patent with hepatopetal flow. There is
large volume ascites in all four quadrants.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening or distention.
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.
Spleen length: 15.3 cm
IMPRESSION:
Cirrhotic liver with splenomegaly and large volume ascites. The main portal
vein is patent.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with hepatic encephalopathy// eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Lung volumes are low. The lungs are clear without focal consolidation.
Cardiomediastinal and hilar contours are normal. No evidence of pulmonary
vascular congestion. No pneumothorax or pleural effusion.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old woman with cirrhosis, ascites, abdominal pain and
nausea after EGD// evaluate for ileus
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: None
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is a
haziness to the abdomen and slight medialization of the colon, consistent with
intra-abdominal fluid. There is no supine evidence of free intraperitoneal
air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. No evidence of dilated bowel to suggest obstruction or ileus.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abdominal distention
Diagnosed with Other ascites
temperature: 97.4
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 101.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | TRANSITIONAL ISSUES:
==================
[ ] Discharged on lasix 40 mg and spirinolactone 100 mg daily
[ ] Please check chem-10 at follow-up appointment and titrate
diuretics as needed based off volume exam and labs
[ ] EGD showed grade I varices but given Child C cirrhosis,
would likely benefit from beta blocker for primary ppx
[ ] Would avoid sedating medications given history of HE
Ms. ___ is a ___ with Child C10 MELD 15 alcoholic cirrhosis
c/b hepatic encephalopathy and ascites who presents with
confusion, abdominal distention, and lower extremity edema
concerning for decompensated cirrhosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / Tetracycline Analogues
Attending: ___.
Chief Complaint:
Fatigue/generalized weakness
Declining hematocrit
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
Ms. ___ is an ___ with h/o chronic fatigue syndrome,
hypothyroidism, and EtOH dependence who is admitted for
fatigue/generalized weakness in the setting of declining Hct.
She was evaluated in ___ clinic on ___ for fatigue and
generalized weakness over the past month, increased from her
baseline chronic fatigue syndrome, diagnosed in ___, and
preventing her from participating in enjoyable activities, such
as grocery shopping, due to extreme physical exhaustion; she
endorses difficulty rising from a chair without support, but no
trouble combing her hair and does not require a cane or walker
for assistance. She was found to have Hct of 26.6 on ___, down
from 34.7 on ___, versus variable baseline Hct ___ since
___, and asked to present to the ED for further evaluation.
Past evaluation for anemia includes: normal Fe (155), ferritin
(68), TIBC (374), transferrin (288), folate (>20), and
haptoglobin (172) in ___ in the setting of Hct of 39.7 and
elevated (1741) VitB12 as recently as ___. Most recent
colonoscopy in ___ was unremarkable. Non-bleeding grade 1
internal hemorrhoids and sigmoid diverticula were noted on ___
flexible sigmoidoscopy, with most recent colonoscopy in ___
unremarkable, and no further evaluation since that time. She
endorses 15-lb unintentional weight gain and mild SOB on
minimal exertion (steps) x2-3 weeks, both of which she
attributes to inactivity, but denies f/c, lightheadedness, chest
pain, abdominal pain, diarrhea/constipation, or melena/BRBPR.
She endorses heavy ibuprofen use, 400mg x4-5 per day over years
for HA. She denies EtOH use since ___. She denies changes in
mood, hair, or nails.
In the ED, initial VS were as follows: 98.4, 106, 132/58, 16,
98% on RA. Admission labs were notable for Hct of 25.7 and
guiac-positive brown stool. She received 1L IVNS, with
resolution of her tachycardia, and was placed on 2LNC oxygen for
comfort. VS prior to transfer were: 98.3, 79, 148/71, 18, 97% on
RA.
Past Medical History:
EtOH dependence c/b peripheral neuropathy
Anxiety
Depression
Chronic fatigue syndrome
Dyshydrotic eczema
HL
Breast cancer s/p lumpectomy, on hormonal therapy
HA
R heel spur
Low back/buttock pain
OSA
H/o hyponatremia
Social History:
___
Family History:
H/o breast cancer in her mother and other maternal family
members. H/o endometrial cancer in her sister. No other known
h/o malignancy, including GI, cardiovascular disease, or DM.
Physical Exam:
On admission:
VS 97.8 173/100 82 22 100% RA
GEN Alert, oriented, no acute distress
HEENT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no thyromegaly
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, ___ SEM at RUSB without radiation
ABD obese soft NT ND normoactive bowel sounds, small reducible
umbilical hernia
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal, strength
___ throughout
SKIN no ulcers or lesions
At discharge:
VS 98 122/60 76 18 96% RA
Otherwise unchanged.
Pertinent Results:
On admission:
CBC: 7.2/25.7/317
Lytes: ___
Coags: 11.2/1/28.5
Inflammatory markers: ESR 80, CRP 13.5
Anemia studies: Retic count 2.1, Fe 50, TIBC 377, folate >assay,
ferritin 42, TRF 290
Thyroid studies: TSH 4, fT4 1.1
At discharge:
CBC: 9.6/25.___/326
Lytes: ___
CXR PA/lateral (___): No acute cardiopulmonary abnormality.
Colonoscopy (___):
Normal mucosa in the whole colon
Diverticulosis of the transverse colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
EGD (___):
Small hiatal hernia
Ulcers in the distal bulb
Erythema in the distal bulb compatible with duodenitis
Erythema in the pre-pyloric region and antrum compatible with
gastritis (biopsy)
Deformed pre-pyloric region
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient/webOMR.
1. Amlodipine 5 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Ibuprofen 400 mg PO Q6H:PRN pain
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Quetiapine Fumarate 12.5 mg PO DAILY:PRN anxiety
6. Aspirin 81 mg PO DAILY
7. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -200 unit Oral BID
8. Vitamin D 1000 UNIT PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Fluoxetine 60 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Quetiapine Fumarate 12.5 mg PO DAILY:PRN anxiety
7. Vitamin D 1000 UNIT PO DAILY
8. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -200 unit Oral BID
9. Omeprazole 40 mg PO BID Duration: 8 Weeks
Please take up to and including ___.
RX *omeprazole 40 mg 1 capsule(s) by mouth twice daily Disp #*57
Capsule Refills:*0
10. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcers
Duodenitis
Gastritis
acute blood loss anemia
chronic fatigue syndrome
Discharge Condition:
Condition: Improved
Mental status: Clear and coherent
Ambulatory status: Independent
Followup Instructions:
___
Radiology Report
HISTORY: Dyspnea on exertion.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The cardiac silhouette size is normal. The mediastinal and hilar contours are
unchanged with mild tortuosity of thoracic aorta again noted. The lungs are
hyperinflated. No focal consolidation, pleural effusion or pneumothorax is
present. Multilevel degenerative changes are seen in the thoracic spine with
anterior bridging osteophytes.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABN LABS
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS, HYPERTENSION NOS, HYPOTHYROIDISM NOS, HX OF BREAST MALIGNANCY
temperature: 98.4
heartrate: 106.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ with h/o EtOH dependence who is
admitted for fatigue/generalized weakness in the setting of
declining Hct, with duodenal ulcers and duodenitis/gastritis on
EGD.
#Normocytic anemia: Patient p/w Hct of 25.7, down from 34.7 on
___, in association with guiac-positive stools. EGD
demonstrated duodenal ulcers without frank bleeding, duodenitis,
and gastritis. Folate and iron studies were unremarkable, and
there was no e/o active hemolysis. H. pylori serology was
negative. Omeprazole 40mg bid was initiated, for a planned
8-week total course, and patient was counseled to avoid NSAIDs.
She remained HD stable with stable Hct throughout, with the
exception of mild, fluid-responsive tachycardia (106) in the ED.
#Fatigue/generalized weakness: Patient with h/o hypothyroidism
and chronic fatigue syndrome p/w fatigue/generalized weakness
without focal neurologic deficits or gait abnormality. Symptoms
likely reflected anemia, with possible contribution from
hypothyroidism (see below) on potentially subtherapeutic
levothyroxine, against a backdrop of chronic fatigue syndrome.
#Hypothyroidism: Patient was found to have TSH of 4.4 on ___ in
the outpatient setting, with repeat TSH of 4 and free T4 of 1.4
on ___. Although on a longtime stable dose of levothyroxine
50mcg daily, she endorsed a 15-lb unintentional weight gain,
possibly rendering her thyroid replacement newly subtherapeutic.
With the exception of generalized weakness, she denied symptoms
of hypothyroidism. Given dynamic thyroid function still within
the therapeutic range, home dose of levothyroxine was continued,
and further adjustment was deferred to the outpatient setting.
She was advised to ensure that levothyroxine was taken at least
4 hours prior to calcium supplements to avoid interaction.
#Depression/anxiety: Although mood remained stable on home
fluoxetine, she reported anxiety associated with being in the
hospital environment. On the morning of discharge, she
experienced extreme anxiety when quetiapine was delayed in
reaching the floor from pharmacy, with symptomatic resolution
once quetiapine became available.
#HTN: She remained largely normotensive on the floor on home
amlodipine, with the exception of SBP to 190s in the setting of
anxiety on the afternoon of HD2, a few hours after returning
from colonoscopy/EGD; intraprocedural pressures remained within
normal limits. There were no symptoms suggestive of end-organ
damage, and BP responded to 200mg PO labetalol x1.
#Transitional issues:
-Normocytic anemia: Patient was prescribed 8-week course of
omeprazole 40mg bid for duodenal ulcers and
duodenitis/gastritis. Repeat Hct is advised on PCP ___.
-Hypothyroidism: Home dose of levothyroxine was continued, but
adjustment may be needed in the setting of recent weight gain.
-HTN: In the setting of isolated SBP to 190s, patient was asked
to keep a BP log at home to present at PCP ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / codeine
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
___ laminectomy, posterior lateral interbody (previous
admission)
History of Present Illness:
___ yo female s/p L5-S1 Lami w/interbody fusion discharged
___ presents to ER with severe pain since ___ evening.
Unrelieved with 8 mg Dilaudid every 4 hours. Denies incontinence
bowel, bladder. No pain, numbness tingling in ___.
tearful, restless due to pain. Reports poor appetite and no BM x
4 days.
Past Medical History:
depression
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: T:100.2 BP:120 / 55 HR:80 R16 O2Sats 100%
Gen: WD/WN, uncomfortable,crying
HEENT: Pupils: 2->1
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, mildly distended BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:full ___ bilat upper and lowers
Sensation: Intact to light touch
Spine: Incision w/ drainage mild erythema
Exam On Discharge:
- incision is clean/dry/intact
- motor is ___ bilaterally and throughout, sensory intact to
light touch
gait is antalgic
- CV - rrr, s1 and s2 nl
- pulm - no acessory muscle use
Pertinent Results:
CT of the Lumbar Spine: ___
IMPRESSION:
1. Status post L5 laminectomy and L5-S1 posterior fusion with
bony graft
material, a small amount of which is identified within the
central canal.
Correlation with surgical procedure is recommended.
2. Dependent edema within the soft tissues posteriorly with foci
of air
posterior to surgical site at L5-S1 and superiorly at T12-L1.
While this may reflect post surgical changes, infection cannot
be excluded. No drainable fluid collection is identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxycycline Hyclate 20 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. ClonazePAM 0.5 mg PO QHS
3. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
4. Diazepam 2 mg PO Q6H:PRN spasm
RX *diazepam 2 mg 1 tab by mouth every six (6) hours Disp #*40
Tablet Refills:*0
5. Gabapentin 600 mg PO TID
RX *gabapentin 300 mg ___ capsule(s) by mouth three times a day
as per taper Disp #*44 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN breakthrough pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4-6h Disp #*100
Tablet Refills:*0
8. Morphine SR (MS ___ 30 mg PO Q8H
RX *morphine [___] 30 mg 1 capsule(s) by mouth as indicated
per taper Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
intractable pain
hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female presents with intractable pain status post L5-S1
laminectomy and posterior lateral interbody fusion.
COMPARISON: Lumbar spine radiograph dated ___.
TECHNIQUE: Multidetector CT images through the lumbar spine were obtained in
the absence of intravenous contrast. Bone algorithm as well as soft tissue
algorithm images were obtained. Coronal and sagittal reformations were
generated and reviewed.
DLP: 883 mGy-cm.
FINDINGS: Patient is status post L5 laminectomy and L5-S1 posterior fusion.
An intervertebral disc spacer is identified at the L5-S1 level. Bone graft
material is idenfied at the lefel of L5 and S1 as well as inferior aspect of
L4, small amounts of which are within the central canal. The remainder of the
bones are unremarkable without fracture or malalignment. Soft tissue windows
demonstrate dependent edema within the subcutaneous tissues posteriorly. There
is additional foci of air posterior to L5-S1 surgical site as well as
superiorly at the T12-L1 level. No drainable fluid collection is identified.
IMPRESSION:
1. Status post L5 laminectomy and L5-S1 posterior fusion with bony graft
material, a small amount of which is identified within the central canal.
Correlation with surgical procedure is recommended.
2. Dependent edema within the soft tissues posteriorly with foci of air
posterior to surgical site at L5-S1 and superiorly at T12-L1. While this may
reflect post surgical changes, infection cannot be excluded. No drainable
fluid collection is identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with OTHER ACUTE POSTOPERATIVE PAIN
temperature: 100.2
heartrate: 80.0
resprate: 16.0
o2sat: nan
sbp: 120.0
dbp: 55.0
level of pain: 10
level of acuity: 3.0 | Mrs. ___ was admitted to the neurosurgical floor for pain
management on ___. Chronic pain was consulted and recommended
Dilaudid PCA. She appeared to have good pain management throught
the night. However, the morning of ___ the patient was in
excrutiating with muscle spasms. She was refusing the valium
secondary to sedation. She felt that the valium put her to sleep
and she did not press the PCA button for a couple hours over
night, which caused her to be in ___ pain this morning. The
valium was decreased to 2mg prn from 5mg. Chronic was contacted
for further recs and titrated her meds accordingly Seen by SW on
___ and recommend support as needed. Pain med were titrated
accordingly on ___ and her pain became better controlled. On
___, sutures were removed in routine fashion. She was
ambulatory with her brace. Pain was controlled. She was
hemodynamically stable. She is set for discharge home in stable
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / doxycycline / erythromycin
base
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
Continuous EEG monitoring
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
PCP: Dr. ___
CC:
_
________________________________________________________________
HPI:
___ year old female with DM, seizure disorder, dementia/cognitive
deficits, neurotic excoriation/prurigo nodularis who presents
with left lower extremity cellulitis, ulceration x3 weeks
despite a course of azithromycin - chosen because of pt's
multiple allergies. She has had worsening erythema of the left
lower extremity despite was visiting nurse performing wound care
services for ulcers on her legs. + shaking chills. She had
diarrhea in ___ but that has since resolved. She reports
increased frequency of urination and defecation. Her stool is no
longer running/liquid. She denies hematocezia. + Black stools. +
Dysuria 2 weeks ago when she had a urinary tract infection.
Her dtr who is her primary caregiver has been overwhelmed but
her husband just got his leg amputated so she has not had time
to take her to the doctor.
+ malaise and fatigue. No measured or subjective fevers.
lle several superficial ulcerations with sorrounding erythema to
upper shin, no calf ttp, 2+ DP pulse
admit for IV abx given failed outpatient mgmt
In ER: (Triage Vitals:
3 | 97.6 | 64 |139/54 |18 |98% RA )
Meds Given:
Vancomycin 1 gm IV
Tmax in ED = 98.3
Fluids given: None
Radiology Studies: none
consults called: none
.
PAIN SCALE: ___ in L leg
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI and includes a few pounds weight
loss.
HEENT: [X] All normal
RESPIRATORY: [+] mild shortness of breath as she lays there
talking with
CARDIAC: [+] A tiny bit above the xiphoid process
GI: Per HPI but she has also been nauseous. She denies emesis.
She has not felt like eating.
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [+] chronic L sided weakness s/p CVA
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
s/p - CABG in ___ LIMA to the LAD
s/p PCI in ___
CVA w/ residual LLE weakness
Hypertension
Hyperlipidemia
Polyneuropathy
Seizure Disorder
Glaucoma
GERD
Anemia
Constipation
Depression
Right Eye Blindness
h/o cocaine abuse
Left ___ toe amputation
s/p cholecystectomy
s/p appendectomy
s/p TAHBSO
s/p bilateral cataract surgery
Social History:
___
Family History:
Reviewed with patient on admission
Father, ___, deceased: MI (___) and CHF
Mother, ___, deceased: DMII, ESRD, Alcoholism
Sister, 80, living: Depression, thromboembolic strok
Sister, ___, deceased: Lung cancer, smoker
Brother, ___, living: ___ Disease
Son, ___, living: Polysubstance abuse
Son, ___, living: Healthy
Physical Exam:
Vitals: 98.1 ___ R 5817 96& on RA
CONS: NAD, comfortable appearing
HEENT: R eye sclerosis and L eye anicteric, poor dentition
CV: s1s2 regular SEM at LUSB without radiation to the carotids
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
MSK:no c/c/e 2+pulses
SKIN: back and on hand multiple scabs, areas of exoriation with
surrounding erythema
LLE: largest area of erhthema = 2.5x3 on L thigh but also
smaller ares of region of erythema wth skin ulcers on the L
shin. Similar region on R shin but decreased in size with no
open lesions. This is also present on the R hand with skin
sloughing and prurulent drainage
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
Pertinent Results:
___ 04:03PM LACTATE-1.1
___ 03:57PM GLUCOSE-273* UREA N-33* CREAT-1.3* SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
___ 03:57PM estGFR-Using this
___ 03:57PM WBC-9.2 RBC-3.87* HGB-10.7* HCT-34.9 MCV-90
MCH-27.6 MCHC-30.7* RDW-13.2 RDWSD-42.8
___ 03:57PM NEUTS-70.4 ___ MONOS-5.2 EOS-2.9
BASOS-0.5 IM ___ AbsNeut-6.46* AbsLymp-1.87 AbsMono-0.48
AbsEos-0.27 AbsBaso-0.05
___ 03:57PM PLT COUNT-263
==============================
___ 08:10AM BLOOD WBC-8.8 RBC-3.73* Hgb-10.3* Hct-33.4*
MCV-90 MCH-27.6 MCHC-30.8* RDW-12.8 RDWSD-41.9 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-258* UreaN-37* Creat-1.6* Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
___ 02:48PM BLOOD Glucose-202* UreaN-38* Creat-1.2* Na-141
K-4.6 Cl-106 HCO3-26 AnGap-14
___ 02:48PM BLOOD ALT-9 AST-12 AlkPhos-138* TotBili-<0.2
___ 02:48PM BLOOD Albumin-3.6
___ 05:40PM BLOOD Valproa-65
___ 02:48PM BLOOD Valproa-57
EEG ___ IMPRESSION: This is an abnormal continuous ICU EEG
monitoring study because of diffuse slowing of the background,
indicative of a mild encephalopathy, which
is non-specific but may be due to medications, infection or
metabolic disturbances. There are no pushbutton activations.
There are no electrographic seizures or epileptiform discharges.
CXR ___: In comparison with the study ___, there are
lower lung volumes.
Allowing for the portable AP position of the patient. There is
little change
in the cardiac silhouette and no definite vascular congestion.
There is the
vague suggestion of some increased opacification in the right
infrahilar
region with a small area of the right heart border that is not
sharply seen.
In the appropriate clinical setting, this could possibly
represent a small
middle lobe consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Donepezil 10 mg PO QHS
7. Fentanyl Patch 100 mcg/h TD Q72H
8. Ferrous GLUCONATE 324 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Memantine 5 mg PO BID
12. Pantoprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. Sertraline 200 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Zonisamide 300 mg PO BID
18. melatonin 3 mg oral QHS:PRN insomnia
19. menthol-camphor-benzyl alcohol ___ % topical TID:PRN
itching
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
22. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezing
23. travoprost 0.004 % ophthalmic QHS 1 drop left eye
24. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
25. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
26. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO DAILY
5. Donepezil 10 mg PO QHS
6. Fentanyl Patch 100 mcg/h TD Q72H
7. Ferrous GLUCONATE 324 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezing
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Memantine 5 mg PO BID
12. Pantoprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. Sertraline 200 mg PO DAILY
16. Zonisamide 300 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Valproic Acid ___ mg PO Q12H
RX *valproic acid (as sodium salt) 250 mg/5 mL 10 ml by mouth
twice a day Disp #*30 Syringe Refills:*0
19. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
20. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
21. melatonin 3 mg oral QHS:PRN insomnia
22. menthol-camphor-benzyl alcohol ___ % topical TID:PRN
itching
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. travoprost 0.004 % ophthalmic QHS 1 drop left eye
25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % apply as instructed twice a
day Disp #*30 Gram Gram Refills:*0
26. Terbinafine 1% Cream 1 Appl TP BID
RX *terbinafine HCl 1 % apply as directed twice a day Disp #*30
Gram Gram Refills:*0
27. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % apply as directed twice a day Refills:*0
28. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
29. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
Pruritus nodularis
Type II diabetes with hyperglycemia
Seizure disorder
___ (resolved)
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: CHEST (PORTABLE AP)
INDICATION: ___ year old woman w/hx of seizure d/o who had seizure possibly x
2 today with worsening hypoxia // r/o aspiration pneumonitis r/o
aspiration pneumonitis
IMPRESSION:
In comparison with the study ___, there are lower lung volumes.
Allowing for the portable AP position of the patient. There is little change
in the cardiac silhouette and no definite vascular congestion. There is the
vague suggestion of some increased opacification in the right infrahilar
region with a small area of the right heart border that is not sharply seen.
In the appropriate clinical setting, this could possibly represent a small
middle lobe consolidation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm swelling, R Leg swelling
Diagnosed with Cellulitis of left lower limb
temperature: 97.6
heartrate: 64.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 54.0
level of pain: 3
level of acuity: 3.0 | ___ hx DM, prurigo nodularis w/excoriations p/w LLE cellulitis
that progressed through oral antibiotics.
# Seizure d/o: 3 min seizure on ___ possible provoked by
hyperglycemia as BS was 419 during event. Hyperglycemia could
have been ___ stress response as pt was previously hypoglycemic
to ___ the evening prior which could have provoke seizure as
well. No s/s worsening infection, sepsis. Neurology consulted
and pt loaded with Valproic acid. EEG monitoring showed no
seizure activity. Patient was continued on zonisamide and
gabapentin. VPA was switched to PO and pt was discharged home to
f/u with outpatient Neurologist. She will need f/u depakote
level in another week, and her neurologist office will arrange
this (I spoke with office scheduling staff after speaking with
inpatient consult team)
# Cellulitis:
#Prurigo nodularis: improved on vancomycin, likely exacerbated
by pruritus resulting in itching and excoriated skin.
Significantly improved after several days of IV antibiotics.
Vancomycin was discontinued after seizure occurred and wounds
were tx with mupirocin only. Dermatology was consulted who
recommended mucopirocin, clobetasol around on closed skin only
for 3 days and then transition to triamcinolone cream to use BID
for 14 days and then cycle (14 days on, 14 days off). Pt also
noted to have fungal infection on the feet which could
exacerbate prurigo nodular. Pt was started on topical anti
fungal tx for 4 weeks.
___: with rise of Cr to 1.6. Responsive to IV + oral intake
# DM: last A1c 7.3 ___, continue Humalog 75/25. Pt had
episode of hypoglycemia likely from incorrect dosing as initial
home meds indicated pt was taking NPH. Pt was switched to home
homolog ___ mix after correction of home meds were updated
with pharmacy's assistance. Pt had no further episodes of
hypoglycemia, though did have some hyperglycemia as above.
# CAD S/P CABG: CP on admission, resolved. EKG wnl and troponin
negative. Continue home statin, aspirin. No further episodes of
chest pain.
.
# Depression: continued home sertraline
# Transitional issues:
-1) patient should have depakote level (trough) in another week
and sent to Dr. ___
-2) Dr ___ will call patient ___ with f/u apptmt
information
-3) Repeat outpatient CXR given subtle findings ___ (without
corroborating clinical infectious signs) to ensure resolution |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Ms. ___ is a ___ year old woman with PMH EtOH abuse and
bipolar disorder who presents from ___ after 2 witnessed
seizures.
Per ___ records, she had 2 seizures approximately ___
minutes apart. The first one was witnessed by boyfriend at home
who called the EMS. He told the EMS that she had not had
anything to drink in 24+ hours. A second seizure happened in
presence of EMS which was described by EMS as generalized. She
was incontinent of urine during that episode. After seizure
ended she was very confused and agitated.
While in the ED at ___, the patient was originally given
multiple doses of 2 mg IV Ativan. The patient was very sedated
for several hours and not arousable with 2 mm pupils. She then
became abruptly agitated, screaming, and incontinent of urine.
Ativan 2 mg, Haldol 5 mg was given to facilitate head CT but did
not work for agitation. Fosphenytoin was given due to possible
atypical seizure activity. Ketamine 100 mg IM was given due to
agitation so they could place a peripheral IV. She was given
etomidate, succinylcholine for intubation.
Labs there showed Hgb 13.7 w/ MCV 108.8, with WBC 14.5 with 12%
bands and 81% PMNs, plts 201. Lactate was 4.2 at 10 am but then
1.1 at 4 pm.
ALT 26, AST 68, Alkphos 46, Tbili 1, Alb 4.8. Na 148, K 3.8, CO2
30, BUN 9, Cr 0.8, Calcium 9.7. UA negative for nitrites, but
with small leuks, 3+ bacteria, ___ WBC. Urine was positive for
benzos.
After intubation she was agitated so she was started on propofol
gtt. At ___ she was started on midazolam gtt as well because
she was difficult to control on high doses of propofol.
In ED initial VS: 114 131/81 18 100% Intubation.
EKG with normal sinus rhythm, no ST changes.
Labs significant for: WBC 12, AST 80, ALT 26.
Patient was given: Midazolam gtt at 1 mg/hr and Propofol gtt.
Imaging notable for: CXR with ETT in place.
On arrival to the FICU, patient is intubated and sedated on
propofol and midazolam gtt.
Boyfriend ___ says that she moved from ___ ___ year ago
and has been drinking secretly since then and trying to hide it
from him. He doesn't know how much she drinks per day but he
found 5 nips in her bag yesterday that had been finished. She
has not taken her medications for bipolar disorder for at least
1 month because she has not gone to fill them. Denies other drug
use. Smokes 1 ppd.
She was feeling unwell and complaining of abdominal pain. She
was vomiting a lot the day prior to the day of admission. In the
AM, he woke up to her screaming and complaining of abdominal
pain. Then she started shaking and she "was looking right
through him" so he called the EMS.
Denies history of seizures.
REVIEW OF SYSTEMS: Unable to assess.
Past Medical History:
EtOH abuse
Bipolar disorder
Probable PTSD
Boyfriend thinks she may have had abortions when she was
younger.
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no skin lesions.
NEURO: intubated and sedated. Pupils 3mm bilaterally, brisk
reactive to light and accommodation.
Pertinent Results:
ADMISSION LABS:
================
___ 08:44PM BLOOD WBC-12.8* RBC-3.12* Hgb-11.5 Hct-35.2
MCV-113* MCH-36.9* MCHC-32.7 RDW-16.9* RDWSD-70.0* Plt ___
___ 07:50PM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-145
K-3.8 Cl-109* HCO3-19* AnGap-17
___ 07:50PM BLOOD ALT-26 AST-80* AlkPhos-47 TotBili-1.0
___ 07:50PM BLOOD Albumin-3.8 Calcium-8.1* Phos-2.7 Mg-1.6
___ 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:02PM BLOOD ___ pO2-108* pCO2-41 pH-7.39
calTCO2-26 Base XS-0
___ 07:55PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 07:55PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM*
___ 07:55PM URINE RBC-4* WBC-8* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-1
___ 07:55PM URINE Mucous-MANY*
___ 07:55PM URINE UCG-NEGATIVE
___ 07:55PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING:
=========
___ CXR IMPRESSION: Endotracheal tube terminates 3.4 cm
above the carina. Enteric tube courses below the diaphragm, out
of the field of view.
___ 07:20AM BLOOD WBC-6.8 RBC-3.09* Hgb-11.3 Hct-33.5*
MCV-108* MCH-36.6* MCHC-33.7 RDW-16.2* RDWSD-64.2* Plt ___
___ 06:55AM BLOOD WBC-9.5 RBC-3.15* Hgb-11.5 Hct-33.8*
MCV-107* MCH-36.5* MCHC-34.0 RDW-16.1* RDWSD-63.4* Plt ___
___ 07:20AM BLOOD Glucose-89 UreaN-3* Creat-0.6 Na-139
K-4.0 Cl-98 HCO3-25 AnGap-16
___ 07:20AM BLOOD ALT-23 AST-34 LD(LDH)-307* AlkPhos-48
TotBili-0.4
___ 07:20AM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.1 Mg-1.9
___ 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBS___ PNEUMONIAE
|
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
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
2. Latuda (lurasidone) 40 mg oral DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. Latuda (lurasidone) 40 mg oral DAILY
5. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
seizure related to alcohol withdrawal
alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with intubated*** WARNING *** Multiple patients with
same last name!// verify ETT placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Endotracheal tube terminates 3.4 cm above the carina. Enteric tube courses
below the diaphragm, out of the field of view. No focal consolidation is
seen. There is no pleural effusion or pneumothorax. Mild basilar atelectasis
is noted.
IMPRESSION:
Endotracheal tube terminates 3.4 cm above the carina. Enteric tube courses
below the diaphragm, out of the field of view.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ETOH, Transfer
Diagnosed with Alcohol dependence with withdrawal, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: u/a
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with PMH EtOH abuse and
bipolar disorder who presents from ___ after 2 witnessed
seizures. She was intubated and initially in the ___ ICU. She
improved and was called out to the medical floor.
#Seizures: Witnessed seizures by boyfriend and EMS in setting of
not drinking EtOH for about 24 hours, felt to be most consistent
with EtOH withdrawal seizures. Unclear if patient has underlying
seizure disorder. OSH NCHCT without abnormalities. Was intubated
for airway protection during NCHCT - ultimately able to be
extubated with difficulty on ___ AM. Was started on a
Phenobarbital taper and did not show any further signs of ETOH
withdrawal. She requested discharge ___.
#EtOH abuse: Patient with history of significant alcohol abuse.
Was started on Thiamine, Folate, and a MVI. Social work was
consulted. Was started on a Phenobarbital taper, as per above.
Pt did not wish for inpt treatment and wanted to return to the
community to see her psychiatrist and therapist.
#Elevated AST: Most likely due to alcohol abuse. Trended her
LFTs. Normalized during admission.
#Hx of bipolar disorder: Held home Lurasidone and Mirtazapine in
the setting of seizures. Restarted on DC. Reportedly, pt has not
been taking in outpt setting. ?compliance. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Levofloxacin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD (2L resting, 4L walking), Afib/flutter (not on AC),
HFpEF, pulmHTN, asthma CKD (b/l Cr 1.7-2), hemolytic anemia (s/p
splenectomy), HTN presenting w/ SOB found to have
hypercarbic/hypoxemic respiratory failure requiring non-invasive
ventilation.
Patient was seen by Dr. ___ on ___ and reported
shortness of breath that was thought in part to be due to
deconditioning. Started on low dose prednisone 5mg daily.
Patient seen by her PCP, ___, on ___, for ongoing
severe shortness of breath with minimal exertion. She had
limited improvement with prednisone 5mg so prednisone was
increased to 10mg daily after discussion with Dr. ___.
During that appointment, the patient expressed that she very
much wants to do everything possible to improve her quality of
life and she would want everything done if her heart or lungs
were to stop if there was any chance that she would be able to
return to her quality of life.
The patient states she felt weak and fell onto her knees
yesterday. Was able to get up and went to bed. Otherwise feeling
well with no trouble breathing at that time. Reportedly fell out
of bed and called EMS from the floor. Found to be hypoxic to the
___ and tachypneic to the ___. Placed on BiPAP and transported
here. States she has some pressure in her chest. Unable to
characterize how long it is been. Has 1+ swelling in the lower
extremities that she says is ongoing. Takes her torsemide at
home. No abdominal pain.
In the ED:
- VS: Temp ___ BP 149/67 HR 77 RR 23 96% BiPAP ___ w/ 8L O2
- Labs notable for
- VBG: 7.18/122, lactate 1.1 -> repeat VBG ___
- CBC notable for plt 135
- trop 0.01 -> 0.02
- CXR: bibasilar atelectasis w/o consolidation, no frank
pulmonary edema
- CT head: no acute process
- EKG: Afib w/ ventricular rate 85, Q wave aVR & V1, largely
unchanged from prior ___
- Received: albuterol nebs, ipra nebs, azithro 500mg, IV
solumedrol 60mg
On arrival to the ___, patient reports history as above with
worsening SOB and fatigue over past month with acute worsening
with onset of lower extremity weakness this AM. She additionally
notes rhinorrhea secondary to allergies and sore throat over the
past few days. She has substernal chest pressure with ambulation
at baseline which has been stable. She has had no n/v/d. She has
urinary frequency at baseline, no dysuria.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
- COPD on home O2 (2L at rest and 4L with walking)
- CHF (EF >60%)
- Atrial fibrillation/flutter on warfarin
- Mild aortic stenosis
- Pulmonary hypertension
- Hypertension
- Asthma
- CKD (Baseline Cr 1.7-2.0)
- HCV s/p transfusion
- Obesity
- Diverticulosis
- Depression
- Hemorrhoids
- Rt knee osteoarthritis
- Hemolytic anemia s/p splenectomy
Social History:
___
Family History:
Hx of cancers on both sides of family; dad with lung,
aunt with breast, and sisters with lung
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 74| 158/73| 38| 90% 4L
GENERAL: Elderly woman, conversant, mild labored breathing
HEENT: Sclera anicteric, MMM, posterior oropharynx with erythema
no exudate
NECK: Supple, non-tender, no massed or LAD.
LUNGS: Poor air movement. No wheezes, occasional rales.
CV: Regular rate, irregular 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,
trace peripheral edema
SKIN: Skin type III. No lesions or eruptions.
NEURO: A&Ox3. No gross focal deficits. CN II-XII intact.
Strength ___ in lower extremities. Moving all extremities with
purpose.
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
VITALS: ___ ___ Temp: 98.4 PO BP: 167/78 R Lying HR: 64
RR:
18 O2 sat: 94% O2 delivery: 2L NC
GENERAL: Alert and in no apparent distress, breathing
comfortably
sitting up in a chair with nasal cannula in place
EYES: Anicteric, pupils equally round
ENT: MMM, OP clear
CV: Irregularly irregular, normal rate, no m/r/g. JVP not
elevated
RESP: Scattered expiratory wheezes, no rhonchi or crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
=================
___ 11:00AM BLOOD WBC-9.1 RBC-3.66* Hgb-11.6 Hct-38.4
MCV-105* MCH-31.7 MCHC-30.2* RDW-16.3* RDWSD-61.4* Plt ___
___ 11:00AM BLOOD Neuts-59.5 ___ Monos-12.5
Eos-0.9* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-5.40
AbsLymp-2.34 AbsMono-1.14* AbsEos-0.08 AbsBaso-0.02
___ 12:55PM BLOOD Glucose-90 UreaN-77* Creat-1.8* Na-148*
K-5.3 Cl-100 HCO3-39* AnGap-9*
___ 02:52AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.3
___ 11:00AM BLOOD ___ pO2-29* pCO2-122* pH-7.18*
calTCO2-48* Base XS-10
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-10.0 RBC-3.74* Hgb-11.9 Hct-39.5
MCV-106* MCH-31.8 MCHC-30.1* RDW-15.6* RDWSD-59.4* Plt ___
___ 06:40AM BLOOD Glucose-88 UreaN-55* Creat-1.2* Na-149*
K-4.7 Cl-99 HCO3-39* AnGap-11
___ 06:40AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2
MICRO:
BCx x2 (___): NGTD
UCx (___):
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 AND STUDIES:
CXR ___
IMPRESSION:
1. Enlarged cardiomediastinal silhouette, slightly more
prominent compared to prior, likely due to patient rotation and
low lung volumes.
2. Bibasilar atelectasis without focal consolidation. No frank
pulmonary
edema.
CT HEAD ___:
IMPRESSION:
1. Motion limited exam without evidence for acute intracranial
abnormalities
or displaced calvarial fracture.
2. Partially visualized paranasal sinus disease.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 100 mg PO QHS
2. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain
- Moderate
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 40 mg PO BID
7. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
8. budesonide 0.5 mg/2 mL inhalation DAILY
9. melatonin 1 mg oral QHS
10. amLODIPine 10 mg PO DAILY
11. HydrALAZINE 10 mg PO Q8H
12. Polyethylene Glycol 17 g PO QID
13. Torsemide 60 mg PO DAILY
14. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild
15. Aspirin 81 mg PO DAILY
16. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
Take for one more dose (last day ___
2. Cetirizine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. PredniSONE 40 mg PO DAILY Duration: 4 Days
Take for 4 more days (last day is ___
7. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild
8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
9. amLODIPine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Budesonide 0.5 mg/2 mL inhalation DAILY
12. Gabapentin 100 mg PO QHS
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. melatonin 1 mg oral QHS
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Omeprazole 40 mg PO BID
18. Polyethylene Glycol 17 g PO QID
19. Torsemide 60 mg PO DAILY
20. HELD- HydrALAZINE 10 mg PO Q8H This medication was held. Do
not restart HydrALAZINE until you follow up with your primary
care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
COPD exacerbation
E.coli UTI
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 dyspnea, hypoxia// evaluate for infection vs copd
TECHNIQUE: Portable supine AP radiograph of the chest
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
Given differences in radiographic techniques, the moderate enlargement of
cardiac silhouette is unchanged, since ___ and ___. Mediastinal veins are
engorged but there is no pulmonary edema. Right pleural effusion is small if
any. Moderate size hiatus hernia is larger. No pneumothorax.
Note healed fracture deformity proximal left humerus.
IMPRESSION:
1. Enlarged cardiomediastinal silhouette, slightly more prominent compared to
prior, likely due to patient rotation and low lung volumes.
2. Bibasilar atelectasis without focal consolidation. No frank pulmonary
edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with fall, difficulty breathing. 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 8.0 s, 16.4 cm; CTDIvol = 49.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Motion artifact limits evaluation particularly through the posterior fossa.
No clear evidence for acute intracranial hemorrhage. No evidence for edema,
mass effect, or acute major vascular territorial infarction. Ventricles and
sulci are prominent consistent with moderate age-related global cerebral
volume loss. Moderately extensive periventricular, subcortical, and deep
white matter hypodensities with bifrontal predominance are nonspecific, but
likely represent sequela of chronic microvascular ischemic disease.
There is no evidence of fracture. There is mild mucosal thickening in the
right maxillary sinus with associated wall sclerosis, which suggests sequela
of chronic inflammation. There is complete opacification of a right anterior
ethmoid air cell with a 5 x 3.5 mm calcified focus which may represent
inspissated secretions versus an osteoma. There is mild mucosal thickening in
several other bilateral anterior ethmoid air cells extending into the
frontoethmoidal sinuses. Mastoid air cells appear grossly well-aerated.
Status post bilateral cataract surgery.
IMPRESSION:
1. Motion limited exam without evidence for acute intracranial abnormalities
or displaced calvarial fracture.
2. Partially visualized paranasal sinus disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ w/ COPD (2L resting, 4L walking), Afib/flutter (not on AC),
HFpEF, pulmHTN, asthma CKD (b/l Cr 1.7-2), hemolytic anemia (s/p
splenectomy), HTN presenting w/ SOB found to have
hypercarbic/hypoxemic respiratory failure requiring non-invasive
ventilation.
=================
ACTIVE ISSUES
=================
#) Hypoxemic/Hypercarbic respiratory failure
#) COPD on O2 ___ at home)
Presented with mixed hypercarbic/hypoxic respiratory failure. Hx
of COPD, ___ PFTs showed FEV1/FVC 66, FEV1 71% predicted,
consistent with moderate disease. Exam notable for poor air
movement and occasional rales. Worsening hypercarbia i/s/o COPD
with otherwise normal CXR concerning for COPD exacerbation. BNP
elevated at ___ though has been as high as >5000 in past, with
no signs of fluid overload. Infection unlikely given lack of
leukocytosis or infiltrate though with sore throat and URI
symptoms. Wells score 0, making PE highly unlikely. Continued to
treat for COPD exacerbation with prednisone 40 mg daily x 7 days
___ last day ___ and azithromycin 250 mg daily x 4
more days ___ last day ___. She improved with these
treatments and at the time of discharge was back to her baseline
home O2 requirement (___).
#Weakness
Patient ambulates with walker at baseline. Experienced weakness
ambulating to bathroom prior to admission in the setting of
worsening SOB. She experienced numbness in lower extremities.
Macrocytic anemia likely in setting of reticulocytosis ___
splenectomy though will rule out B12 deficiency. Sensation and
strength intact. B12 was wnl, but borderline. Pt was evaluated
by ___ who recommend rehab.
- As an outpatient, PCP could consider checking methylmalonic
acid as B12 was borderline
#) Elevated troponin
Troponin 0.01 -> 0.02 in the ED. EKG without acute ST changes or
T wave inversions. Patient with substernal chest
pressure/tightness. Likely type II NSTEMI i/s/o COPD
exacerbation.
#) Hypernatremia
Na 148 on admission. Possible a component of dehydration though
other labs are not hemoconcetrated. Will encourage oral intake
and monitor.
=================
CHRONIC ISSUES
=================
#) Atrial fibrillation
Patient has been off anticoagulation since previous
gastrointestinal bleed in ___.
- RC: Normal rate, not on rate control
- AC: not on AC. Continue aspirin 81 mg daily
- trend ___
#HFpEF
BNP elevated at ___ though weight stable and without gross
overload on exam or imaging. Initially held home torsemide in
setting of recent fall and weakness; this was resumed prior to
discharge.
#) CKD
Baseline Cr 1.7-2.0. Her Cr was better than baseline on
discharge (1.2).
#) Hypertension
On amlodipine, isosorbide ER, and hydralazine at home. BP stable
in the normal range. Her home regimen was initially held in the
FICU. On the medicine floor, her home amlodipine and isosorbide
was resumed. Her hydralazine was held until she can follow up
with her PCP and can be resumed as her blood pressure allows.
#) Chronic pain
#) Osteoarthritis
Continued her home gabapentin.
Held hydrocodone-acetaminophen 5 mg-325mg ___ tab q8h prn as she
was not having significant pain.
#) Chronic Thrombocytopenia
#) Hemolytic anemia s/p splenectomy
Hemoglobin and platelets currently at baseline.
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo Type I Diabetic w/ ESRD on dialysis,
gastroparesis who presents with nausea and vomiting. Pt reprots
increased nausea and vomiting over the past week, that was being
managed okay by his home zofran until today. he denies any
recent worsening of his blood sugars, fevers, or infectious
symptoms. He reports epigastric pain that is ___ and
nonradiating. He has been vomiting bilious vomiti and ___
blood or coffee grounds. He was last admitted for a
gastroparesis flare in ___ and is followed by Dr. ___ as an
___ as last saw him on ___. Because of his symptoms
today he msiseed his dialysis sessiona nd was unable to take his
medications because he could not keep anything down.
In the ED, initial VS were: 97.9 ___ 16 99%. He was
given 4mg IV zofran x 2, 5mg IV morphine x2, metoclorpromide
10mg IVx1, and IV famotidine. Labs were ntable for a K of 5.2.
On arrival to the floor he cotninues to complain on nausea and
is vomiting into a bucket. He continues to have epigastric pain
taht is nonradiating and reports he was feeling better for a
couple of hours when he got the meds he got in the ED. He
denies any orthopnea, dyspnea, peripheral edema, chest pain,
palpitations. He last moved his bowels two days prior to
admission and last ate a real meal the day prior to admission,
he is passing gas.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Type I diabetes: since age ___, complicated by gastroparesis,
retinopathy (s/p laser treatment), nephropathy
- ESRD on HD MWF, started ___
- s/p left brachiocephalic AV fistula created on ___
- s/p angioplasty of the arterial anastomosis, mid cephalic and
cephalic arch, complicated by extravasation and mid-fistula
hematoma
- ___ syndrome
- Hypertension
- Asthma
- HLD
- anemia of chronic disease
Social History:
___
Family History:
Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer
Physical Exam:
On admission:
VS: 97.7, 168/96, 95, 18, 97%RA BS 77 Wt 81.6kg
GENERAL: ill appearing but nontoxic, sitting up in bed over an
emesis bucket, in NAD.
HEENT: PEERLA, with some lid lag. No oropharyngeal lesions
NECK: supple
LUNGS: CTA bilat, no rales noted
HEART: RRR, referred murmur from the fistula on the LUE
ABDOMEN: decreased bowel sounds but normal pitch, soft. "tender"
to deep palpation, but no guarding or rebound or tensing of the
muscles. Some tenderness in the epigastrium
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
On discharge:
VS: 99.1, 194/108, 84, 16, 96%RA
GENERAL: appears in NAD, comfortable receiving HD.
HEENT: EOMI
NECK: supple
LUNGS: CTA bilat, no rales noted
HEART: RRR, referred murmur from the fistula on the LUE
ABDOMEN: soft, NT/ND, no guarding or rebound or tensing of the
muscles
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
On admission:
___ 06:00PM BLOOD WBC-8.3 RBC-3.89* Hgb-12.1* Hct-35.1*
MCV-90# MCH-31.0 MCHC-34.4 RDW-13.5 Plt ___
___ 06:00PM BLOOD Neuts-70.4* ___ Monos-3.1 Eos-3.3
Baso-0.8
___ 06:00PM BLOOD ___ PTT-35.0 ___
___ 06:00PM BLOOD Glucose-83 UreaN-64* Creat-10.7*# Na-138
K-5.2* Cl-94* HCO3-21* AnGap-28*
___ 06:00PM BLOOD Lipase-47
___ 05:55AM BLOOD Calcium-8.9 Phos-6.9* Mg-2.2
___ 06:21PM BLOOD ___ pO2-73* pCO2-34* pH-7.45
calTCO2-24 Base XS-0
On discharge:
___ 06:29AM BLOOD WBC-8.6 RBC-3.10* Hgb-9.7* Hct-28.8*
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.6 Plt ___
___ 06:29AM BLOOD Glucose-235* UreaN-31* Creat-7.1*# Na-136
K-4.1 Cl-93* HCO3-29 AnGap-18
___ 06:29AM BLOOD Albumin-4.0 Calcium-8.4 Phos-5.6* Mg-2.0
Micro:
___ KUB
No evidence of obstruction. Non-specific bowel gas pattern.
Radiopaque density seen throughout the colon likely secondary to
miralax use
or recent barium ingestion. No recent barium studies at ___
have been
performed. Please correlate clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. Metoclopramide 10 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWEEK
5. Lisinopril 10 mg PO DAILY
hold for sbp<100 or hr<60
6. Glargine 5 Units Breakfast
Glargine 4 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
7. Erythromycin 250 mg PO TID
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. FoLIC Acid 1 mg PO DAILY
10. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness
11. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWEEK
2. Erythromycin 250 mg PO TID
3. FoLIC Acid 1 mg PO DAILY
4. Metoclopramide 10 mg PO TID
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness
10. Lisinopril 20 mg PO DAILY
11. Glargine 5 Units Breakfast
Glargine 4 Units Dinner
Insulin SC Sliding Scale using novolog Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroparesis
Diabetes mellitus type 1, uncontrolled woth complications
HTN, uncontrolled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with abdominal pain and presents for evaluation.
Question ileus.
COMPARISON: Abdominal radiographs from ___ and ___.
FINDINGS:
There is a radiopaque density seen throughout the colon. The bowel gas
pattern is unremarkable. There is no evidence of distension. There is no
free air or pneumatosis. There is no soft tissue calcification. The
visualized osseous structures are unremarkable.
IMPRESSION:
No evidence of obstruction. Non-specific bowel gas pattern.
Radiopaque density seen throughout the colon likely secondary to miralax use
or recent barium ingestion. No recent barium studies at ___ have been
performed. Please correlate clinically.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: NAUSEA/VOMITING
Diagnosed with DIAB NEURO MANIF IDDM, GASTROPARESIS
temperature: 97.9
heartrate: 103.0
resprate: 16.0
o2sat: 99.0
sbp: 196.0
dbp: 111.0
level of pain: 10
level of acuity: 3.0 | ___ yo M w/ PMH of Type I diabetes complicated by gastroparesis,
ESRD on HD via left upper extremity fistual, retinopathy,
hypertension who presents with nausea and vomiting consistent
with a flare of gastroparesis.
#Gastroparesis- unclear what the trigger to this episode was as
his blood sugars have been wtihin range and he denies any
symptoms to lead to infectious etiology. Lipase was within
normal limits and thus acute pancreatitis was not likely.
Patient's flare was controlled with IV Reglan, Zofran and
Ativan. On hospital day 3, patient no longer required
antiemetics and was stable on PO Reglan. After tolerating a BRAT
diet without any abdominal pain, patient was discharged.
Patient's outpatient GI doctor was contacted while patient was
in-house. He will follow-up with Dr. ___ to discuss possible SC
Reglan.
#Hypertension- Initially, patient's blood pressure was elevated
to 190s in the setting of vomiting and also missed dialysis
session on ___ and was unable to take his po
lisinopril given his vomiting. Of note, patient was on labetalol
previously however this was stopped as he was getting
orthostatic. His systolic pressures ranged from 140-180 and
received one time doses of hydralazine for systolics above 180.
On day of discharge, patient remained persistently hypertensive
with systolics 170-180s and thus had lisinopril increased from
10mg to 20mg daily in addition to clonidine patch.
#ESRD on HD- pt normally gets ___ sessions and missed his
session on day of admission. He was euvolemic on exam even after
getting 500cc of fluids in the ED. He had no orthopnea or signs
of volume overload. He received HD on ___ and
___. He was contnued on sevelamer and
nephrocaps. He will continue HD as outpatient ___.
#Diabetes- patient has type 1 DM and ___ was consulted.
___ team recommended tightening control of blood glucose by
having patient start carb counting and also suggested adjusting
Novolog sliding scale by starting at 2u of insulin given for
fingerstick BG at 71-120 (excluding bedtime). Patient has ___
follow-up on ___.
#Anemia- chronic and within his baseline range |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose / gluten
Attending: ___.
Chief Complaint:
Abdominal pain, hematemesis
Major Surgical or Invasive Procedure:
EGD with biopsies ___
History of Present Illness:
As per HPI in H&P by Dr. ___ ___:
___ with PMH of UC on rectal mesalamine only, celiac
disease, hypothyroidism and recent admission at ___ from
___ to ___ for acute pancreatitis of unclear etiology
who
re-presented to the ED with recurrence of her abdominal pain,
oral intolerance with emesis, and a single episode of
hematemesis. Regarding her prior admission, no etiology of her
pancreatitis found (IgG subclasses pending at discharge but IgG4
subsequently returned not elevated, MRCP without obvious
etiologic structural abnormality, ___ 106, no gallstones, patient
denied EtOH and is not obese). She states that she was pain-free
on discharge ___. However, shortly after advancing her diet
over
the next ___ days, she developed recurrence of epigastric
abdominal pain radiating to her back. She decreased her diet
back
to clear liquids, but the pain persisted and has continuously
gotten worse. Over the last 3 days, she has had epigastric
abdominal pain radiating through to the back associated with
morning nausea and vomiting, usually just one episode. Today she
had an episode of small-volume hematemesis, perhaps at teaspoon
of blood. She has not measured her temperature, but has felt
subjectively sweaty. She also states she feels a sensation of
chest discomfort peaking with intensity of her abdominal pain,
and difficulty taking a deep breath due to pain.
In the ED, initial VS were 98.5 95 124/89 18 100% RA. Exam was
notable for epigastric ttp without rebound or guarding. Labs
were notable for WBC 11.0 w/ no left shift, Hgb 13.6, plts 321,
BUN/Cr ___, lytes all WNL, LFTs WNL, Lipase 1301, Albumin
3.9,
INR 1.2, uHCG negative, UA with 30 protein and few bacteria,
Lactate 1.3. CT A/P showed mild edema in the pancreatic head
improved from ___, with no evidence of peripancreatic fluid
or necrosis. Again seen was 3 cm lesion in hepatic segment VIII
(suspected FNH), mixing artifact within the SMV not thought to
represent thrombosis. CXR was without pleural effusion or other
acute disease. EKG was without evidence of ischemia. She
received 1L NS, 1L LR, and was started on LR @ 200 cc's/hr,
Morphine 4 mg IV x2, ondansetron 4 mg x1, acetaminophen 1g IV,
and was admitted for further workup.
On arrival to the floor, she reports ongoing mild epigastric
abdominal pain that is slightly improved with pain medication.
ROS: A 10-point review of systems was performed and was negative
with the exception of those systems noted in the HPI. "
Past Medical History:
Celiac disease
Ulcerative Colitis - followed by ___ at ___
___
Hypothyroidism
Social History:
___
Family History:
Negative for thyroid disease. Parents, both age ___, are alive
and well. Sister, age ___, has type 1 diabetes
(diagnosed at ___ months of age).
Physical Exam:
ADMISSION EXAM:
VITALS: 98.7 PO 112 / 70 88 18 96 RA
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, bowel sounds present. ___
sign negative. There is mild tenderness to palpation in the
epigastrium, nontender elsewhere.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
Vitals: 98.3 122 / 79 62 18 96 Ra
GENERAL: Alert, NAD, appears well
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.
GI: Abdomen soft, non-distended, no TTP in epigastrium.
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, no ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 11:50AM BLOOD WBC-11.0* RBC-4.64 Hgb-13.6 Hct-41.7
MCV-90 MCH-29.3 MCHC-32.6 RDW-11.9 RDWSD-38.9 Plt ___
___ 11:50AM BLOOD ___ PTT-28.6 ___
___ 11:50AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-138
K-5.0 Cl-100 HCO3-24 AnGap-14
___ 11:50AM BLOOD Albumin-3.9 Calcium-9.7 Phos-4.9* Mg-1.8
___ 11:50AM BLOOD ALT-15 AST-19 AlkPhos-82 TotBili-0.3
___ 11:50AM BLOOD Lipase-1301*
___ 06:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:15AM BLOOD tTG-IgA-2
___ 12:03PM BLOOD Lactate-1.3
MICRO:
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING:
CT abd/pelvis with contrast (___):
IMPRESSION:
1. Mild edema in the pancreatic head improved from the prior
exam
dated ___. No peripancreatic fluid collections
identified.
2. Approximately 3 cm lesion in hepatic segment VIII, previously
characterized on MRCP as a likely region of focal nodular
hyperplasia. Follow-up recommendations as per the MRCP dated ___.
3. Mixing artifact within the SMV, similar in appearance to the
prior exam.
CXR PA/Lat (___):
IMPRESSION:
No acute cardiopulmonary process.
EGD: gastritis and duodenitis with biopsies taken in the stomach
and duodenum; no source of bleeding identified
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-7.4 RBC-3.77* Hgb-11.1* Hct-33.2*
MCV-88 MCH-29.4 MCHC-33.4 RDW-11.8 RDWSD-38.0 Plt ___
___ 06:30AM BLOOD Glucose-77 UreaN-6 Creat-0.4 Na-140 K-3.9
Cl-100 HCO3-24 AnGap-16
___ 06:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Concerta (methylphenidate HCl) 36 mg oral DAILY
3. Mesalamine home dose mg PO AS PER YOUR HOME DOSE
4. Mesalamine (Rectal) home dose mg PR HOME DOSE
5. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Concerta (methylphenidate HCl) 36 mg oral DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent pancreatitis
Hematemesis due to likely ___ tear
ulcerative colitis
gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with a history of ulcerative colitis, celiac
disease, hypothyroidism, recently admitted for pancreatitis 10 days ago, who
presents with recurrent symptoms of pancreatitis.// pneumomediastinum? free
air under diaphragm?
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or pneumothorax.
The cardiomediastinal silhouette is within normal limits. No
pneumomediastinum. No free air below the diaphragm. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT abdomen pelvis with IV contrast.
INDICATION: ___ with hx pancreatitis, initially improved but now returned
with recurrent severe epigastric painNO_PO contrast// complication of
pancreatitis?
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 1.5 s, 0.5 cm; CTDIvol = 7.2 mGy (Body) DLP = 3.6
mGy-cm.
2) Spiral Acquisition 6.2 s, 48.6 cm; CTDIvol = 9.6 mGy (Body) DLP = 466.0
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: Reference is made to the CT abdomen pelvis with contrast dated ___ in the ___ dated ___.
FINDINGS:
LOWER CHEST: Dependent atelectasis is seen bilaterally. The visualized lung
fields are otherwise within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A 3.2 cm enhancing lesion is again seen within hepatic segment
VIII, previously evaluated on ___ dated ___ and felt to possibly
represent focal nodular hyperplasia. The liver otherwise demonstrates
homogenous attenuation throughout. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: There is trace edema in the pancreatic head, improved from the
prior. No evidence of concerning focal pancreatic lesions or pancreatic
ductal dilatation. No evidence of pancreatic necrosis. No peripancreatic
fluid collections.
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 an unchanged 2.3 cm simple appearing renal cyst in the upper pole of
the right kidney. There is no evidence of concerning focal renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is not well assessed on CT but appears grossly
unremarkable. No evidence of small-bowel obstruction. 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. Uterus and adnexae are within normal limits for
patient's age.
LYMPH NODES: No lymphadenopathy within the abdomen or pelvis.
VASCULAR: No abdominal aortic aneurysm. Again seen is mixing artifact within
the superior mesenteric vein including a small apparent central filling,
similar in overall appearance to the CT abdomen pelvis dated ___ and
the MRCP from the same date. No evidence of pseudoaneurysm formation within
limitation of the portal venous phase study.
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 edema in the pancreatic head improved from the prior exam dated ___. No peripancreatic fluid collections identified.
2. Approximately 3 cm lesion in hepatic segment VIII, previously characterized
on MRCP as a likely region of focal nodular hyperplasia. Follow-up
recommendations as per the MRCP dated ___.
3. Mixing artifact within the SMV, similar in appearance to the prior exam.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Hematemesis
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 98.5
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 89.0
level of pain: 10
level of acuity: 3.0 | SUMMARY/ASSESSMENT:
___ with PMH of UC on mesalamine, celiac disease, hypothyroidism
and recent admission at ___ from ___ to ___ for acute
pancreatitis of unclear etiology who re-presented to the ED with
recurrence of her abdominal pain, oral intolerance with emesis,
and a single episode of hematemesis concerning for recurrent vs.
persistent pancreatitis. She was found to have gastritis and
likely ___ tear. Her pain improved with conservative
management. She was followed by GI during her hospitalization
and tolerated PO intake prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
Nausea, vomiting, and abdominal pain.
Major Surgical or Invasive Procedure:
None during current admission.
History of Present Illness:
___ female with history of C difficile colitis s/p
subtotal colectomy, end ileostomy this past year c/b small bowel
perforation necessitating laparotomy/SBR, s/p ileostomy takedown
and ileo-rectal anastomosis in ___, now presenting to
the ED with nausea, vomiting, and abdominal pain.
Patient was admitted approximately 3 weeks ago for similar
symptoms of nausea, abdominal spasms, and diarrhea. Her immodium
was titrated at that time. She was seen in clinic two days ago
with similar complaints, with recommendations to up-titrate her
immodium because she had continued to have loose bowel movements
(up to 8 per day).
Past Medical History:
Diverticulitis complicated by microperf s/p sigmoid resection
SBO ___ adhesions s/p lysis of adhesions
Gastroesophageal reflux disease
Supraventricular tachycardia / atrial fibrillation (not
currently anticoagulated)
Hyperlipidemia
Anxiety
PSH:
Abdominoplasty
Sigmoid resection ___ diverticulosis ___
___ open subtotal colectomy/end ileostomy (___)
___ exploratory laparotomy, washout, SBR (___)
___ ileostomy takedown (___)
Social History:
___
Family History:
Mother had CAD diagnosed at an early age.
Physical Exam:
VS: T 97.9, HR 88, BP 135/85, R 16, O2 sat 98 RA
General: NAD, alert and conversant
HEENT: sclera anicteric, mucus membranes moist, nares clear,
trachea midline
CV: regular rate, rhythm, no audible signs of afib, no
appreciable murmurs, rubs, or gallops
Pulm: clear to auscultation bilaterally, respirations unlabored
on room air
Abd: NT, ND, well-healing midline laparotomy incision and former
ostomy site without e/o hernia or infection. Scaphoid abd.
MSK: warm, well perfused, no c/c/e
Neuro: alert, oriented to person, place, time
Pertinent Results:
___ 9:35AM Gluc-119* BUN-25* Cr-1.3* Na-132* K-4.8 Cl-92*
HCO3-23 AnGap-22*
___ 09:35AM BLOOD WBC-7.8 RBC-4.89# Hgb-14.4# Hct-42.5#
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.1 Plt ___
___ 7:00AM Glucose-84 BUN-24* Creat-0.8 Na-136 K-4.3 Cl-104
HCO3-22 AnGap-14
___ 07:00AM BLOOD WBC-9.1 RBC-3.68* Hgb-10.8*# Hct-32.3*#
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.7 Plt ___
KUB ___:
On the upright radiograph there are a few air-fluid levels in
the upper abdomen and a dilated loop of small bowel in the left
upper quadrant measuring up to 5.8 cm. Otherwise, there is a
relative paucity of bowel gas in the mid and lower abdomen
although some gas is seen in the pelvis. There is no free air.
There is no evidence of pneumatosis. There is mild leftward
curvature of the lumbar spine.
Radiology Report
INDICATION: ___ year old woman with hx of Cdiff colitis s/p subtotal colectomy
and end ileostomy ___ and small bowel perforation s/p laparotomy and small
bowel resection ___ complicated post-operative courses including SBO
requiring placement of peg tube for decompression which was removed after
hospitalization, she had ileostomy takedown on ___/ and readmission for
SBO on ___ which was managed conservatively. Now p/w increased abdominal
pain // rule out perforation or obstruction
TECHNIQUE: Supine and upright AP radiographs of the abdomen
COMPARISON: Radiographs of the abdomen ___ and ___. CT
abdomen and pelvis ___.
FINDINGS:
On the upright radiograph there are a few air-fluid levels in the upper
abdomen and a dilated loop of small bowel in the left upper quadrant measuring
up to 5.8 cm. Otherwise, there is a relative paucity of bowel gas in the mid
and lower abdomen although some gas is seen in the pelvis or there is chain
suture from prior anastomosis. There is no free air. There is no evidence of
pneumatosis. There is mild leftward curvature of the lumbar spine.
IMPRESSION:
A few air-fluid levels in the upper mid abdomen and a dilated loop of apparent
small bowel in the left upper quadrant could be further evaluated with CT. No
free air.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING
temperature: 97.7
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 112.0
level of pain: 7
level of acuity: 3.0 | ___ was admitted to the inpatient Colorectal Surgery
Service on ___ after presenting to the ED with signs and
symptoms of ileus. It was determined that this was likely
related to uptitration of the imodium in clinic a few days prior
to this admission. She continued to pass flatus and liquid stool
throughout her admission, and she required no invasive
operations or interventions during her stay. She was hydrated
appropriately. Nausea, vomting, and abdomimal pain dramatically
improved after holding her ammonium dose, and she was gradually
restarted on a diet, which she tolerated without difficulty. She
subsequently had a large amount of liquid stool output, so it
was decided to start cholestyramine and lomotil. She was also
started on gabapentin to assist in weaning Ms. ___ off of
narcotic medications for pain control. Her gabapentin dose will
be titrated and adjusted as an outpatient.
Of note, Ms. ___ creatinine at the time of her admission
was elevated to 1.3 (from patient's baseline of about 0.7). She
was hydrated aggressively the first night of her admission, and
her creatinine the day after her admission was back down to 0.8
and remained within close range of her baseline.
At the time of discharge, Ms. ___ was tolerating a regular
diet, she was having an appropriate amount of daily stool
output, and she had no abdominal pain, nausea, or vomiting. She
has been given discharge instructions, and she will be scheduled
to follow-up with Dr. ___ as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Iodinated Contrast Media - IV Dye / Bactrim /
clindamycin HCl / Benadryl
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ tear old male with past medical history of GBM,
s/p multiple resections s/p left craniotomy for resection on
___ with Dr. ___ at ___. The patient was discharged to
home on ___. Today the patient was at ___ as
well as having an MRI here at ___. He was accompanied by his
mother who stated they had gone back to their home town, ___ and the patient was in his bedroom sleeping at
approximately 2100 when she heard him making strange sounds and
walked in to his bedroom to find him seizing. She then called
911
and the patient was transferred to ___ which the
patient mothers states is approximately 15 minutes from their
home. On arrival to ___ the patient continued to be
seizing
and was given 1 gram of Phenytoin, 10 mg of dexamethasone, and a
total of 10 mg of Lorazepam. The patient was then transferred to
___ via Medflight for further care and evaluation for concern
of status epilepticus. On arrival Neurosurgery was consulted for
further recommendations. Unable to obtain ROS as the patient was
intubated on arrival to ___. The patients mother states that
the patient had not been febrile today, and has been taking
Keppra 1500 mg PO BID as instructed.
Past Medical History:
- Recurrent glioblastoma
- Anxiety
- Depression
Social History:
___
Family History:
His father died at age ___ from a myocardial infarction.
He has a paternal half brother who has diabetes and heart
disease, as well as a paternal half sister who is healthy.
Physical Exam:
============
ON ADMISSION
============
PHYSICAL EXAM:
O: T:98.1 BP: 122/99 HR: 105 R:18 O2Sats: 100%
Gen: Intubated, ill appearing male, sutures to Left craniotomy
site CDI
HEENT: Pupils: 4-3 mm bilaterally
Neuro:
Mental status: Intubated, sedation off for exam, no eye opening
to noxious stimuli
Orientation: Intubated, No verbal output at time of exam
Language: Intubated, No verbal output at time of exam
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
Motor: Increased tone to BUE, R>L. ___ withdraws to noxious
stimuli, LUE localizes to noxious stimuli, RLE triple flexion to
noxious stimuli, LLE localizes to noxious stimuli.
============
ON DISCHARGE
============
Oriented to self and hospital - simple words, yes/no
appropriately, EO spontaneous, PERRL 3-2 mm bilaterally (pupils
known to be anasicoric at times). Left upper extremity full,
right upper contracted, follows simple commands, Incision
CDI-healing well, face asymmetric
Motor
D B T G IP Q H AT ___ G
R ___ ___ 2 0 0 0
L ___ ___ 5
Pertinent Results:
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Status-post left craniotomy with partial removal of a large
frontoparietal mass thought to be recurrent GBM. Surgical
resection cavity with surrounding hemorrhage and large
hypodensity which may be post-surgical and residual tumor and
edema.
2. Interval increase in right shift of normally midline
structures, now 11 mm compared to 9-10 mm on MR from ___ and
5-8 mm from early post-operative images on ___ and ___.
3. Interval increase in soft tissue low-density fluid
collection likely
post-operative seroma along left calvarium (7.8 x 1 cm).
4. No definite new large infarct, although difficult to assess
in left
hemisphere.
5. Overall unchanged appearance of hypodensities in right
insular cortex and cerebellar hemisphere.
___ CHEST (PORTABLE AP)
IMPRESSION:
No pneumothorax or pleural effusion. Heart size normal. Lungs
clear. ETT and esophageal drainage tube in standard placements.
Right central venous infusion catheter ends close to the
superior cavoatrial junction.
CT HEAD W/ CONTRAST Study Date of ___ 10:47 AM
IMPRESSION:
1. Low-density fluid collection along the left calvarium
adjacent to the
craniotomy site is slightly smaller than on the prior study, now
measuring 6.7 x 1.2 cm.
2. Postsurgical changes after left craniotomy and resection of
the recurrent left frontal parietal glioma.
3. Decreased rightward shift of normally midline structures,
now measuring approximately 6 mm, compared with 11 mm
previously.
Neurophysiology Report EEG Study Date of ___
IMPRESSION: This is an abnormal continuous video-EEG monitoring
study due to an asymmetry of activity between the hemispheres,
with a loss of faster
frequencies over the left, as well as a diffusely slow and
disorganized
background with bursts of generalized slowing. These findings
indicate a
widespread encephalopathy with signs of cortical dysfunction
over the left
hemisphere and potentially deep midline brain dysfunction. No
epileptiform
activity was seen at any time.
Medications on Admission:
ATOVAQUONE, BUSPIRONE, DEXAMETHASONE, DULOXETINE,
FAMOTIDINE,FLUCONAZOLE, GABAPENTIN, LACTULOSE, LEVETIRACETAM,
LORAZEPAM, METHYLPHENIDATE, NYSTATIN, ONDANSETRON HCL,
PROCHLORPERAZINE MALEATE, ACETAMINOPHEN, DOCUSATE SODIUM,
SENNOSIDES
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Atovaquone Suspension 1500 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. Gabapentin 300 mg PO QHS
8. Heparin 5000 UNIT SC BID
9. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
10. MethylPHENIDATE (Ritalin) 5 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Senna 8.6 mg PO BID
13. Phenytoin Infatab 75 mg PO DAILY
In between BID dosing please
14. Phenytoin Infatab 100 mg PO BID
15. LevETIRAcetam 500 mg PO BID
16. Dexamethasone 4 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Requires 2 assist.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man with intubation. Evaluate ETT.
TECHNIQUE: Portable AP radiograph view of the chest.
COMPARISON: None.
FINDINGS:
The ETT tip is in standard position, projecting approximately 2.7 cm from the
carina. A right Port-A-Cath tip projects over the expected region of the
right atrium. The enteric tube tip and side-port project over the expected
region of the stomach in the left upper mid abdomen.
The lungs are well-expanded and clear. No focal consolidation, effusion, or
edema. The apices are incompletely evaluated. There is right apical pleural
thickening. The mediastinum is not widened. The heart is normal in size.
No acute osseous abnormality on this nondedicated exam.
IMPRESSION:
1. ETT in standard position.
2. Incompletely evaluated apices; right apical pleural thickening.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ man with recent surgery here with seizures. Evaluate
for hemorrhage.
The patient's name is ___ with MRN ___.
Per OMR, the patient has a history of recurrent GBM, status-post left re-do
craniotomy for resection of a large portion of the known GBM and duraplasty 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, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR ___ study dated ___
Post-operative head CT dated ___
Post-operative MR brain dated ___
FINDINGS:
The patient is status-post re-do left craniotomy to remove the majority of a
large left frontoparietal recurrent glioma. A low-density fluid collection
with a small amount of subcutaneous emphysema along the left calvarium
adjacent to the craniotomy site is overall similar to the MR yesterday but
increased in size since the immediate post-operative imaging. This soft
tissue collection measures approximately 7.8 x 1 cm and is most likely a
post-operative seroma (series 2, image 19). Expected post-surgical changes
are seen in the resection cavity, overall similar to the recent MR. ___
peripheral hyperdense material is compatible with hemorrhage, most likely post
surgical (series 2, image 25, 22 ; series 602b, image 56). Surrounding
hypodensity probably reflects a combination of edema, post treatment changes,
and residual tumor. There is associated local mass effect and approximately
11 mm right shift (series 2, image 20) which is more compared to the immediate
postop exams (5-8 mm) and may be minimally increased compared to the MR
yesterday (9-10 mm). Hypodensity in the left basal ganglia is overall
unchanged from the immediate postop images (series 2, image 14, 16, 13). Any
underlying infarct in this area of tumor in resection bed difficult to assess
on this CT exam. Pneumocephalus has since resolved.
Persistent hypodensity in the right insular cortex and right cerebellum appear
overall similar to the prior exams referenced above. Periventricular white
matter hypodensities are otherwise also similar and may reflect post treatment
changes.
The visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are essentially clear. The visualized portion of the
orbits are
unremarkable.
IMPRESSION:
1. Status-post left craniotomy with partial removal of a large frontoparietal
mass thought to be recurrent GBM. Surgical resection cavity with surrounding
hemorrhage and large hypodensity which may be post-surgical and residual tumor
and edema.
2. Interval increase in right shift of normally midline structures, now 11 mm
compared to 9-10 mm on MR from ___ and 5-8 mm from early post-operative
images on ___ and ___.
3. Interval increase in soft tissue low-density fluid collection likely
post-operative seroma along left calvarium (7.8 x 1 cm).
4. No definite new large infarct, although difficult to assess in left
hemisphere.
5. Overall unchanged appearance of hypodensities in right insular cortex and
cerebellar hemisphere.
NOTIFICATION: The findings, images, and impression were discussed with ___
___, M.D. by ___, M.D. in person on ___ at 1:30 AM, 2 minutes
after discovery of the findings. Also discussed with Dr. ___ on the
telephone on ___ at 125 am.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with apical ptx // reassess ptx reassess
ptx
IMPRESSION:
Compared to chest radiographs ___ at 00:15.
No pneumothorax or pleural effusion. Heart size normal. Lungs clear. ETT
and esophageal drainage tube in standard placements. Right central venous
infusion catheter ends close to the superior cavoatrial junction.
Radiology Report
EXAMINATION: CT HEAD W/ CONTRAST
INDICATION: ___ year old man with GBM s/p multiple resections now w/ fluid
collection/drainage at wound concerning for infection vs. seroma. Evaluate
for fluid collection status post craniotomy.
TECHNIQUE: Contiguous axial images of the brain were obtained after the
intravenous administration contrast agent.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head of ___.
FINDINGS:
Again, the patient is post left craniotomy and resection of the previous large
left frontoparietal recurrent glioma. The previously described low-density
fluid collection along the left calvarium, adjacent to the craniotomy site,
measures 6.7 x 1.2 cm, previously 7.8 x 1.0 cm (4:17). Postsurgical changes
are again noted, including hyperdense blood products adjacent to the resection
cavity. No evidence of pneumocephalus. Evaluation for residual tumor is
limited on the current CT. Associated mass effect with rightward shift of
normally midline structures has decreased, now measuring approximately 6 mm,
compared with 11 mm previously. Hypodensity in the left basal ganglia is
overall unchanged (4: 15). Again common is difficult to evaluate for
underlying infarct in the area of tumor in the resection bed.
Previously described hypodensity in the right insular cortex and right
cerebellum are overall similar to the prior study.
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. Low-density fluid collection along the left calvarium adjacent to the
craniotomy site is slightly smaller than on the prior study, now measuring 6.7
x 1.2 cm.
2. Postsurgical changes after left craniotomy and resection of the recurrent
left frontal parietal glioma.
3. Decreased rightward shift of normally midline structures, now measuring
approximately 6 mm, compared with 11 mm previously.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with seizures, in need of enteral access for med
administration // NGT placement NGT placement
COMPARISON: Comparison to ___ at 09:46
FINDINGS:
Portable AP semi-upright chest radiograph ___ at 21:05 is submitted.
IMPRESSION:
Right Port-A-Cath is unchanged in position. Nasogastric tube courses below
the diaphragm with the side port and tip projecting over the proximal stomach.
Interval extubation. Cardiac and mediastinal contours are stable. Lungs
remain clear. No pleural effusions or pulmonary edema. No pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Intubated
Diagnosed with Unspecified convulsions
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | On ___, Mr. ___ was transferred to the ED from an OSH after
being found seizing by his mother. He was intubated at the OSH
and treated with phenytoin, dexamethasone and a total of 10mg
lorazepam. He was then medflighted to ___ in status
epilepticus. He was admitted to the ICU and remained intubated
and sedated with propofol. He was loaded with Dilantin, started
on maintenance dosing and placed on continuous EEG. His EEG
monitoring did not show any seizure activity, so sedation was
weaned. While off propofol, the patient did not have any
changes in his EEG. He was extubated per ICU protocol.
On ___ the patient remained neurologically stable. His
corrected Dilantin level was 22.4, per Neurology recommendations
there was no change to his dosing. The patients respiratory
status was stable, and he continued on room air. The patient was
pre-medicated and a CTA was performed. His Gabapentin dose was
changed to 300 mg at bedtime which is his home dose. His blood
and urine cultures had no growth to date from ___. His EEG
was discontinued per Neurology recommendations as the patient
has not had any seizures during his stay. His sutures were
removed, and he was transferred to the floor on telemetry.
On ___ the patient remained hemodynamically and Neurologically
stable. His Dilantin trough at 0600 was 18.1. He passed a
bedside nursing swallow evaluation, and a formal speech and
swallow consult was pending.
On ___ the patients neurological exam remained stable. His
blood cultures continued to be pending from ___ and ___. The
patient was cleared by the speech and swallow team for regular
solids consistency as well as thin liquids. His diet was
advanced.
On ___ he remained stable. He was evaluated by ___ who
recommended rehab at discharge. He was mildly orthostatic and
was ordered for TEDs and abdominal binder for OOB.
On ___ the patient remained neurologically stable. Hi phenytoin
level was 21.1, it was discussed with ___ and his Dilantin
dosing was adjusted. He was cleared for discharge to rehab by
the Neurosurgical team and was discharged to ___.
The patient was given follow up instructions. His blood cultures
at discharge continued to be pending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Barbiturates / Nifedipine / Propranolol / phenobarbital /
Labetalol
Attending: ___.
Chief Complaint:
Chest pain and palpitations
Major Surgical or Invasive Procedure:
Pharmacologic Nuclear stress test
History of Present Illness:
Mr. ___ is a ___ year old man with history of CAD s/p two
stents in ___ and ___, HTN, TIIDM, Hepatitis C who presented
with several weeks of palpitations and following an episode of
chest pain this morning. Pt has been experiencing palpitations
after awakening for the past several weeks. He describes it as a
pounding and racing in his chest and only occurs when he wakes
up. They are self resolving. They occur prior to drinking his
morning cofee. Up until this morning, they were not associated
with chest pain, shortness of breath, cough, diaphoresis,
headache/lightheadedness,or weakness.
This morning when he awoke,had palpitations, but also developed
left-sided "squeezing" chest pain that lasted for roughly 30
minutes. Pain mostly left side and radiated to the right
shoulder and was associated with shortness of breath. No
ameliorating or exacerbating factors, and it was self-limited.
Not changed with inspiration or positional. On ___, he was
given a Holter monitor to evaluate his palpitations, but the
leads fell off the first night and he was unable to bring it in
to the hospital yesterday. He has had similar chest pain in the
past, prior to his past two stents. Last stress on ___
showed no signs of ischemia.
In the ED, intial vitals were 98.7 91 192/92 16 96% ra. CXR, EKG
and trops were normal. He was admitted for further evaluation of
chest pain.
On admission, denies chest pain, shortness of breath, cough,
palpitations, arm pain. ROS of all systems negative.
Past Medical History:
Cardiac Risk Factors:(+)Diabetes,(+)Dyslipidemia,(+)Hypertension
Cardiac History:
-diastolic dysfunction
-PCI: ___ with DES to mid-LAD, ___ with DES x2 to LCx
and OM3
OTHER PAST MEDICAL HISTORY (adapted from previous notes):
-Hepatitis C
-IBS
-History of IV opiate/polysubstance abuse, detailed in social
history
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory..
Physical Exam:
Admission:
VS: 98.8 P: 116 BP 183/97 RR22 95% RA 143.9 KG
General: Pt appears obese, comfortable, in NAD A&Ox3
HEENT: NCAT, EOMI, ___, no oralmucosal lesions
Neck: No masses
CV: s1s2 rrr, no murmurs, rubs, or gallops, unable to assess
JVP
Lungs: CTABL with no m/r/g
Abdomen: Distended with no tenderness, g/r, +NBS
GU: No foley
Ext: Trace b/l pitting edema, no clubbing, cynaosis
Neuro: CN ___ grossly intact with no focal deficits
Skin: No rashes
Pulses: 2+ in b/l dp/tp
DISCHARGE
VS: Tc 98.0 Tm 98.4 177/96 70 20 96% RA
General: Pt appears obese, comfortable, in NAD A&Ox3
HEENT: NCAT, EOMI, ___, no oralmucosal lesions
Neck: No masses
CV: s1s2 rrr, no murmurs, rubs, or gallops, unable to assess
JVP
Lungs: CTABL with no m/r/g
Abdomen: Distended with no tenderness, g/r, +NBS
GU: No foley
Ext: Trace b/l lower ext pitting edema, no clubbing, cyanosis
Neuro: CN ___ grossly intact with no focal deficits
Skin: No rashes
Pulses: 2+ in b/l dp/tp
Pertinent Results:
Admission:
___ 07:54AM BLOOD WBC-7.5 RBC-4.46* Hgb-12.5* Hct-37.6*
MCV-84 MCH-28.0 MCHC-33.3 RDW-14.9 Plt ___
___ 07:54AM BLOOD Glucose-176* UreaN-23* Creat-1.3* Na-141
K-3.5 Cl-104 HCO3-26 AnGap-15
___ 06:50AM BLOOD Calcium-8.6 Mg-1.9
___ 05:05PM BLOOD cTropnT-<0.01
___ 07:54AM BLOOD cTropnT-<0.01
___ 02:35AM BLOOD CK-MB-2 cTropnT-<0.01
Discharge Labs:
___ 06:00AM BLOOD WBC-7.3 RBC-4.17* Hgb-12.2* Hct-34.9*
MCV-84 MCH-29.3 MCHC-35.1* RDW-14.9 Plt ___
___ 06:00AM BLOOD Glucose-102* UreaN-19 Creat-1.1 Na-143
K-3.3 Cl-105 HCO3-28 AnGap-13
___ 6:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
Studies:
___ Imaging CARDIAC PERFUSION PHARM
IMPRESSION: 1. Normal cardiac perfusion with LVEF of 54%. 2.
Mildly enlarged left ventricle, decreased from prior study.
Cardiovascular ReportStressStudy Date of ___
INTERPRETATION: This ___ yo IDDM man s/p PCI to the ___ and OM
___
was referred to the lab for evaluation of chest pain and
palpitations.
The patient was administered 0.142 mg/kg/min of IV Dipyridamole
over 4
minutes. The patient denied any arm, neck, back, or chest
discomfort
throughout the procedure. There were no significant ST segment
changes
seen during the infusion or in recovery. The rhythm was sinus
without
ectopy. Appropriate HR response to the infusion. Baseline
systolic
hypertension with a flat BP response to the Dipyridamole. Two
minutes
post-isotope injection, the patient received 75 mg of IV
Aminophylline.
Normal heart rate response to dipyridamole.
IMPRESSION: No anginal symptoms or significant ST segment
changes to
pharmacologic stress. Nuclear report sent separately.
CHEST (PA & LAT)Study Date of ___ 6:38 AM
FINDINGS: Frontal and lateral views of the chest. No pleural
effusion,
pneumothorax or focal airspace consolidation. Heart size is top
normal.
Normal mediastinum and hilar structures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO DAILY PRN anxiety
2. Glargine 110 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
3. Verapamil SR 120 mg PO Q24H
hold for HR <60, SBP <100
4. Nabumetone 500 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Lisinopril 20 mg PO DAILY
hold for SBP <100
7. BusPIRone 10 mg PO QAM
8. BusPIRone 5 mg PO QHS
9. HydrALAzine 25 mg PO BID
10. Atorvastatin 80 mg PO HS
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. BusPIRone 10 mg PO QAM
4. BusPIRone 5 mg PO QHS
5. HydrALAzine 25 mg PO BID
6. Glargine 110 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
7. Lisinopril 20 mg PO DAILY
8. Lorazepam 0.5 mg PO DAILY PRN anxiety
9. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet extended release 24
hr(s) by mouth twice a day Disp #*60 Tablet Refills:*0
10. Nabumetone 500 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Musculoskeletal chest pain
Hypertension
Anxiety
Diastolic heart failure
Secondary Diagnosis:
Diabetes mellitus type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Palpitations, rule out and infectious process.
COMPARISON: Chest radiograph ___.
FINDINGS: Frontal and lateral views of the chest. No pleural effusion,
pneumothorax or focal airspace consolidation. Heart size is top normal.
Normal mediastinum and hilar structures.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: PALPITATIONS
Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 98.7
heartrate: 91.0
resprate: 16.0
o2sat: 96.0
sbp: 192.0
dbp: 92.0
level of pain: 4
level of acuity: 2.0 | ___ male with a hx of CAD s/p PCI and anxiety presenting with
palpitations and chest pain since this morning.
#Chest Pain: Pt presented with chest pain associated with
palpitations. He could not provide a clear and consistent
history regarding quality of chest pain. He often noted it was
sharp, substernal, radiating to left arm but not changed with
inspiration or positional. While it was initially associated
with palpitations, he had several episodes of chest pain during
admission without palpitations. His EKG was at baseline this
admission with T wave flattening in I/avL, Troponins were
negative multiple times this admission. A nuclear perfusion
stress test was normal. Given history and objective findings,
chest pain does not appear to be secondary to coronary artery
disease. It may be related to anxiety or musculoskeletal in
nature. He was continued on home metoprolol, aspirin, and
atorvastatin.
#Palpitations: Patient promotes feeling new onset heart
palpitations starting 10 days prior to admission. They were self
resolving and only occurred very early in the morning (prior to
drinking coffee). He was asymptomatic during episodes until
developing associated chest pain described above. He did not
have any episodes or abnormal events on tele during admission.
His metoprolol succinate was increased to 100mg BID. Patient
will have a home event monitor upon d/c. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chloroquine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a past medical history significant for
IDDM, CKD, sCHF (EF 40%) who presented to ___ for evaluation
of chest pain, and is being admitted to ___ for hypoglycemia
and insulin titration. Briefly, pt developed pressure-like
left-sided ___ chest pain yesterday radiating down his Left
arm. Pain was moderately bothersome to him. There was no
association with activity. Pt noted some episodes of shortness
of breath, but this was not temporally associated with chest
pain. Pt also endorse nausea and some diaphoresis. Pt has had
this chest pain before for the past 4 months, and notably had a
clean cardiac catheterization on ___. No recent weight
gain. Pt has had history ___ edema, but feels that it is
improved from prior. Pt called his PCP, and was told to present
to the ED for further follow up.
Pt has notably also had labile blood sugars recently, and was
seen in the ED earlier this week for hypoglycemia, at which time
his levamir dose was decreased. His FSBG have continued to be
fairly labile with occasional highs and lows at home. No
polyuria.
On presentation to the ED, VS were: 98.7 90 178/86 16 100%. He
was notably hypoglycemic to 37 at triage. PE notable for ___
swelling. Labs significant for BUN/Cr 59/4.5; H/H 9.7/29.0
(baseline Hgb ___, Pro-BNP 9136, CK 1045 and UA w/trace blood
and protein of 600. Patient was given 80 PO lasix. Trops were
0.17->0.14, MB flat. CXR suggestive of minimal to mild
interstitial edema. Pt received CT received CT A/P which showed
(1) no nephrolithiasis, hydronephrosis, or hydroureter, (2)
Small right pleural effusion, and (3) Few enlarged
retroperitoneal and inguinal lymph nodes. Patient's FSBG ranged
from 80-185, and his AM levemir was held. He was seen by ___,
who recommended potentially starting NPH in the AM. They
recommended admission to medicine for glycemic control.
On admission to the floor, VS were: 98; 166/82; 86; 18; 100% RA.
On the floor, pt reports no chest pain or SOB. He feels more or
less at his baseline. He also notes that he previously had
inflammation and fluid around his heart while he was in ___,
and he took unknown medication for this. He also notes a history
of taking herbal supplements, including a "tea" from ___
for diabetes, which he only took once.
ROS: (+) per HPI. No fevers. +chills, mild night sweats. No
dysuria. No abdominal pain. + nausea, no vomiting.
Past Medical History:
-Type II DM (last A1c = 8.2 on ___
-CKD stage G3b/A3, GFR 30 - 44 and albumin creatinine ratio >300
mg/g
-Coronary artery disease
-Depression
-Diabetes, Type 2, uncontrolled, with eye compl.
-Dizziness
-Hyperlipidemia
-Hypertension
-Obesity
-Orthostatic hypotension
-Vitamin D deficiency
Social History:
___
Family History:
-Father passed away from stroke at ___
-Brother with heart disease
Physical Exam:
On Admission:
VS: 98; 166/82; 86; 18; 100% RA
FSBG: 269
General: Pleasant, well-appearing. NAD. AOx3
HEENT: NT/AT. EOMI.
LAD: No cervical/supraclavicular LAD appreciated
CV: RRR. No MRG. JVP ~9cm
Pulmonary: Mild bibasilar crackles. No wheezes, rales, rhonchi.
Abdomen: Soft. Mild TTP in epigastric region. Nondistended. No
HSM appreciated.
Extremities: WWP. 2+ DP/radial pulses, equal bilaterally. Trace
___ pitting edema.
Neuro: CNII-XII grossly intact. Moving all extremities with
purpose
On Discharge:
VS: 98.6/98.2; 141-165/79-89; 80-91; 18; 100% RA
FSBG: 159-294; 83-140
General: Pleasant, well-appearing. NAD. AOx3
HEENT: NT/AT. EOMI.
LAD: No cervical/supraclavicular LAD appreciated
CV: RRR. No MRG. JVP ~8cm
Pulmonary: CTAB. No wheezes, rales, rhonchi.
Abdomen: Soft. Mild TTP in epigastric region. Nondistended. No
HSM appreciated.
MSK: No TTP of chest wall. Point TTP in Left shoulder
approximately at biceps tendon.
Extremities: WWP. 2+ DP/radial pulses, equal bilaterally. Trace
___ pitting edema.
Neuro: CNII-XII grossly intact. Moving all extremities with
purpose
Pertinent Results:
On Admission:
___ 07:44PM BLOOD WBC-7.3# RBC-3.53* Hgb-9.7* Hct-29.0*
MCV-82 MCH-27.6 MCHC-33.5 RDW-14.6 Plt ___
___ 07:44PM BLOOD Neuts-44.9* Lymphs-42.2* Monos-7.0
Eos-5.3* Baso-0.5
___ 07:44PM BLOOD Glucose-39* UreaN-59* Creat-4.5* Na-146*
K-5.1 Cl-107 HCO3-25 AnGap-19
___ 07:44PM BLOOD ALT-21 AST-27 CK(CPK)-1045* AlkPhos-92
TotBili-0.2
___ 07:44PM BLOOD CK-MB-5 proBNP-9136*
___ 07:44PM BLOOD Albumin-3.1*
___ 07:53PM BLOOD Glucose-40* Lactate-1.1 K-4.6
Cardiac Enzymes:
___ 07:44PM BLOOD cTropnT-0.17*
___ 07:45PM BLOOD CK-MB-4 cTropnT-0.14*
___ 02:34AM BLOOD CK-MB-2 cTropnT-0.16*
___ 07:25AM BLOOD CK-MB-2 cTropnT-0.17*
CK:
___ 07:44PM BLOOD ALT-21 AST-27 CK(CPK)-1045* AlkPhos-92
TotBili-0.2
___ 07:45PM BLOOD CK(CPK)-832*
___ 07:20AM BLOOD CK(CPK)-625*
On Discharge:
___ 07:25AM BLOOD WBC-4.9 RBC-3.25* Hgb-9.0* Hct-26.8*
MCV-82 MCH-27.6 MCHC-33.5 RDW-14.8 Plt ___
___ 07:25AM BLOOD Glucose-148* UreaN-51* Creat-4.7* Na-144
K-4.4 Cl-111* HCO3-24 AnGap-13
___ 07:25AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.8
MICROBIOLOGY:
___ BCX x1: Pending
IMAGING:
___ CXR:
IMPRESSION:
Suggestion of minimal to mild interstitial edema
___ CT A/P w/o Contrast:
IMPRESSION:
1. No nephrolithiasis, hydronephrosis, or hydroureter.
2. Small right pleural effusion.
3. Few enlarged retroperitoneal and inguinal lymph nodes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO BID
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Vitamin D ___ UNIT PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Torsemide 80 mg PO QAM
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. HydrALAzine 50 mg PO Q6H
9. Labetalol 400 mg PO TID
10. Torsemide 40 mg PO QPM
11. Levemir 19 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
12. Cyanocobalamin 50 mcg PO DAILY
Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using Novalog Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 10 Units before
BED; Disp #*1 Vial Refills:*0
2. Amlodipine 5 mg PO BID
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Cyanocobalamin 50 mcg PO DAILY
5. HydrALAzine 50 mg PO Q6H
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Labetalol 400 mg PO TID
8. Torsemide 80 mg PO QAM
9. Torsemide 40 mg PO QPM
10. Vitamin D ___ UNIT PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Insulin-dependent diabetes mellitus
Chronic kidney disease
Secondary:
Chronic systolic CHF
Hypertension
Chronic anemia
Hyperlipidemia
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 SOB // Eval for Volume Overload
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The cardiac silhouette is stable, mild to moderately enlarged. Mediastinal
contours are stable and unremarkable. No large pleural effusion is seen
although a trace pleural effusion be difficult to exclude. Subtle prominence
of the interstitial markings suggests minimal to mild interstitial edema. No
pneumothorax is seen.
IMPRESSION:
Suggestion of minimal to mild interstitial edema
Radiology Report
INDICATION: Flank pain. Evaluate for stone.
TECHNIQUE: Non-contrast scan: 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.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: DLP: 879.1 mGy-cm (abdomen and pelvis.
IV Contrast: None.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
There is dependent atelectasis bilaterally. There is a small right pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The nonenhanced appearance of the liver is within normal
limits. The gallbladder is normal in appearance, without stone or obvious
gallbladder wall thickening.
PANCREAS: The pancreas is homogeneous in attenuation.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are normal in size and configuration
bilaterally.
URINARY: The kidneys are symmetric and normal in size, without stone or
hydronephrosis. The ureters are normal in caliber.
GASTROINTESTINAL: Small and large bowel loops are normal in caliber, without
obvious wall thickening or evidence of obstruction. Although the appendix is
not visualized, there are no secondary signs of acute appendicitis.
RETROPERITONEUM: Several retroperitoneal lymph nodes are prominent, with an
enlarged lymph node noted at the level of the renal artery measuring 1.2 cm
(02:40). No enlarged mesenteric lymph nodes are appreciated.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
Urinary bladder wall thickening is likely related to underdistention. Pelvic
lymph nodes are noted, increased in number, though not pathologically enlarged
by CT size criteria. There are multiple prominent inguinal lymph nodes, some
of which are enlarged, measuring up to 1.2 cm in the right groin. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The nonenhanced appearance of the prostate is
unremarkable.
BONES AND SOFT TISSUES:
There is no osseous lesion concerning for neoplasm or infection. An area of
soft tissue stranding in the anterior abdominal wall may be related to prior
medication injections.
IMPRESSION:
1. No nephrolithiasis, hydronephrosis, or hydroureter.
2. Small right pleural effusion.
3. Few enlarged retroperitoneal and inguinal lymph nodes.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Chest pain, Leg swelling
Diagnosed with DIAB W MANIF NEC ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.7
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 178.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | ___ y/o M w/PMHx IDDM, sCHF and CKD IV who presented to ___ ED
with chest pain and was admitted for hypoglycemia.
#DM2 c/b hypoglycemia: Patient notably had several episodes of
hypoglycemia while on levamir prior to admission. This was felt
to be secondary to the use of levamir in the setting of
worsening renal function. He was maintained on Humalog insulin
sliding scale while in the hospital as well as glargine 10U QHS
per ___ recommendations, with good control of FSBG. He was
discharged with Novalog insulin sliding scale and Glargine 10U
QHS.
# Elevated CK: Patient w/CK of >1000 on admission. He was
otherwise asymptommatic. His atorvastatin was discontinued in
this setting, and he was discharged with a plan to consider a
lower dose/potency statin as an outpatient.
#Chest pain: Patient's chest pain was felt to be
musculoskeletal, and he notably had point tenderness on his
anterior shoulder during this hospitalization, which mimicked
his chest pain. He was discharged with a plan to consider
physical therapy as an outpatient.
#SOB: Patient's shortness of breath resolved by admission. He
was not felt to have had an acute heart failure exacerbation,
and his shortness of breath was felt to be related to
hypoglycemia with a possible component of anxiety.
#CKD: Pt's creatinine was similar to recent creatinine values.
He notably was being considered for peritoneal dialysis as an
outpatient. He was discharged with a plan to follow up with
nephrology.
#Chronic CHF: Patient was not felt to be in decompensated heart
failure during this admission. He was continued on home
torsemide. Discharge weight was 102.7kg
# Lymphadenopathy: Patient was noted to have retroperitoneal and
inguinal lymphadenopathy on admission. He was discharged with a
plan to follow up on this as an outpatient with repeat CT.
# Chronic anemia: Patient's H/H was stable as compared with his
baseline, felt to be secondary to renal disease.
# HLD: As above, patient's atorvastatin was discontinued in the
setting of elevated CK. He was discharged with a plan to
consider pravastatin or a lower dose of statin as an outpatient.
# HTN: Patient was continued on home amlodipine, Imdur, Hydral,
labetalol and torsemide |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Abacavir / Nevirapine / Dapsone / Amoxicillin /
Clindamycin / Bactrim DS / Atorvastatin / amlodipine /
lisinopril / benzonatate
Attending: ___.
Chief Complaint:
Blood in Stoma
Major Surgical or Invasive Procedure:
EGD on ___
Colonoscopy on ___
History of Present Illness:
___ year old male, hx cirrhosis/liver failure, diverticular
bleed,
HIV with chief complaint of bleeding in his stoma since ___. Thought bleeding had resolved ___, but resumed
___.
Also states stools were light yesterday, more normal in
appearance today. Reports bright red blood coming from middle of
stoma. Was seen at ___ on ___, but left due
to wait. When the bleed resumed on ___ he called Dr. ___
___
recommended he come to ___.
Of note patient was seen at ___ on ___ with
chest pain and shortness of breath. Per PCP note on ___
patient had an increased troponin and fixed defect on ETT
without
ischemia. He reports he has a follow up appointment for TTE with
his cardiologist on ___. Some concerns given bleeding risk if
patient were to require DAPT. Denies recurrence of chest pain.
In the ___ initial vitals: 99.1 64 125/74 18 100% RA
-Exam notable for: Soft, non-tender. Positive bowel sounds.
Stoma
site looks healthy, beef red, no surrounding erythema, no
clinical signs of infection. Ostomy bag contains normal
appearing
stool, no e/o blood.
- Labs notable for:
CBC: wbc 7.1, Hb 12.3, HCT 35.9, platelets 79
Chem7: Unremarkable
LFTs: ALT 35, AST 75, AP 104, LDH 276, Tbili 2.9,
Coags: ___ 17.8, PTT 32.1, INR 1.6
Trops: .06->.___.6
EKG: rate 58, sinus rhythm, L axis devitation, no ST or T wave
changes QTc 483
- Consults: GI/hepatology: will admit him for further work up in
house (endocopy/CT). Trend HB.
- Patient was given: mIVF, Magnesium oxide, Zofran, Truvada,
Nadolol 20mg, Pantoprazole 40mg, Spironolactone 25mg,
Rousuvastatin, Potasium, Lasix 20mg, Rifaxamin 550mg.
On arrival to the floor patient reports he has had less bleeding
from his colostomy today. There is a small amount of bleeding on
the R side of the ostomy, which he feels is from irritation. He
has had significantly reduced appetite x 1 week. He feels
generally fatigued. Has some pain in his lower abdomen. Had
emesis ___ yesterday AM; non-bloody contained food particles. At
baseline empties ostomy ___ times per day. For the last week
ostomy output has been runny and has been emptying ___ times per
day. Denies fevers, chills, chest pain, shortness of breath,
dysuria, abdominal distension, leg swelling.
Past Medical History:
___ cirrhosis with recent alcoholic hepatitis
HIV with recently detectable viral load (previously undetectable
for ___ years)
Diverticulosis s/p diverticulitis x2
Hypertension
Hypothyroidism
Social History:
___
Family History:
MotherDeceased54GASTRIC CANCER
FatherDeceased___ CANCER
SisterLiving67PACEMAKER PLACEMENT
No history of liver disease.
Physical Exam:
ADMISSION EXAM:
VS:98.1PO 106 / 66L Lying 64 18 98 RA
___: NAD, A&O x3
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Significant midline scar, closed with superficial
scale.
LUQ ostomy in place. Brown stool in bag. Do of blood on L aspect
of ostomy. Slight suprapubic tenderness to palpation,
hepatomegaly noted.
EXTREMITIES: 1+ edema to mid shin.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: 24 HR Data (last updated ___ @ 1215)
Temp: 98.0 (Tm 98.5), BP: 121/73 (106-121/56-73), HR: 70
(70-76), RR: 18, O2 sat: 99% (97-99), O2 delivery: RA
___: NAD, A&O x3
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Significant midline scar, closed with superficial
scale. LUQ ostomy in place with clear/yellow liquid. Non-ttp.
EXTREMITIES: 1+ edema to mid shin.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 12:17PM BLOOD WBC-7.1 RBC-3.65* Hgb-12.3* Hct-35.9*
MCV-98 MCH-33.7* MCHC-34.3 RDW-14.2 RDWSD-51.7* Plt Ct-79*
___ 12:17PM BLOOD Neuts-47.5 ___ Monos-22.8*
Eos-1.7 Baso-0.7 Im ___ AbsNeut-3.38 AbsLymp-1.91
AbsMono-1.62* AbsEos-0.12 AbsBaso-0.05
___ 12:17PM BLOOD ___ PTT-34.0 ___
___ 12:17PM BLOOD Plt Smr-VERY LOW* Plt Ct-79*
___ 12:17PM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-137
K-3.7 Cl-97 HCO3-30 AnGap-10
___ 01:19AM BLOOD WBC-6.0# Lymph-27 Abs ___ CD3%-69
Abs CD3-1125 CD4%-20 Abs CD4-330* CD8%-48 Abs CD8-772*
CD4/CD8-0.43*
___ 12:17PM BLOOD ALT-40 AST-92* AlkPhos-114 TotBili-4.0*
___ 12:17PM BLOOD Lipase-62*
___ 12:17PM BLOOD cTropnT-0.05*
___ 12:17PM BLOOD Albumin-3.2* Calcium-9.4 Phos-3.0 Mg-1.5*
___ 12:27PM BLOOD Lactate-1.7
NOTABLE LABS:
___ 07:23AM BLOOD WBC-5.6 RBC-3.34* Hgb-11.3* Hct-32.7*
MCV-98 MCH-33.8* MCHC-34.6 RDW-14.4 RDWSD-51.6* Plt Ct-58*
___ 12:17PM BLOOD cTropnT-0.05*
___ 01:19AM BLOOD CK-MB-11* cTropnT-0.06*
___ 10:07AM BLOOD cTropnT-0.05*
___ 01:19AM BLOOD HIV1 VL-2.6*
DISCHARGE LABS:
___ 05:51AM BLOOD WBC-5.7 RBC-3.77* Hgb-12.8* Hct-37.0*
MCV-98 MCH-34.0* MCHC-34.6 RDW-14.6 RDWSD-52.6* Plt Ct-64*
___ 05:51AM BLOOD Plt Ct-64*
___ 05:51AM BLOOD ___ PTT-36.1 ___
___ 05:51AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-138
K-4.4 Cl-104 HCO3-19* AnGap-15
___ 05:51AM BLOOD ALT-31 AST-57* AlkPhos-101 TotBili-4.7*
___ 05:51AM BLOOD Albumin-3.6 Calcium-9.9 Phos-4.2 Mg-1.7
MICRO:
___ 2:15 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
___ Abdominal U/S:
No definite abdominal wall varices are identified, within the
limitations of a limited study with the stoma obscuring
significant portions of the adjacent abdominal wall. Of note,
there are a few abdominal wall varices identified on prior CT of
the abdomen and pelvis performed ___.
___ CTA A/P:
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries. The
proximal SMA is partially thrombosed, seen on prior.
LOWER CHEST: Minimal atelectasis is noted in the lung bases.
There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver contour is nodular, in keeping with
known cirrhosis. It is hypoattenuating throughout suggesting
fatty Liver. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
Multiple portosystemic collaterals and esophageal varices are
again demonstrated. 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 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: Small bowel loops demonstrate normal caliber,
wall thickness and enhancement throughout. Patient is status
post left hemicolectomy with diverting colostomy in the left mid
abdomen (303; 77). No peristomal varices are noted. No
evidence of active intrapulmonary bleeding. A well
circumscribed 3 cm lesion is noted in the right lower quadrant
and AP additional 2.5 cm in the right mid abdomen could
represent too walled-off old blood. Extensive diverticulosis is
noted throughout colon. 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.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No evidence of active arterial extravasation. No evidence
of parastomal varices.
2. 2 well-circumscribed intra-abdominal lesions measuring 3 cm
and 2.5 cm
likely represent fluid collections with old hemoperitoneum.
3. Cirrhotic Liver.
___ EGD:
-Varices in distal esophagus
-Normal mucosa in the rest of esophagus
-Congestion, petechiae and mosaic mucosal pattern in the stomach
fundus and stomach body compatible with portal hypertensive
gastropathy.
-Normal mucosea in the whole examined duodenum.
___ Colonoscopy:
-Normal mucosa in the rest of the colon and 30 cm into the
terminal ileum.
-Moderate diverticulosis of the colon.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ferrous Sulfate 325 mg PO DAILY
2. RiTONAvir 100 mg PO BID
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Darunavir 600 mg PO BID
5. Rifaximin 550 mg PO BID
6. Vitamin D ___ UNIT PO DAILY
7. Furosemide 20 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. magnesium gluconate 27 mg magnesium (500 mg) oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Rosuvastatin Calcium 20 mg PO QPM
14. Spironolactone 25 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Dolutegravir 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Dolutegravir 50 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO DAILY
8. magnesium gluconate 27 mg magnesium (500 mg) oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nadolol 20 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Rifaximin 550 mg PO BID
13. RiTONAvir 100 mg PO BID
14. Rosuvastatin Calcium 20 mg PO QPM
15. Spironolactone 25 mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleed
Secondary diagnosis: ETOH cirrhosis, acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with ETOH cirrhosis, diverticular bleed s/p
colectomy now with bleed from ostomy. Evaluate for parastomal varices.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Limited views were performed around the ostomy site and through the ostomy
bag. Loops of bowel are seen. No definite abdominal wall varices are
appreciated.
IMPRESSION:
No definite abdominal wall varices are identified, within the limitations of a
limited study with the stoma obscuring significant portions of the adjacent
abdominal wall. Of note, there are a few abdominal wall varices identified on
prior CT of the abdomen and pelvis performed ___.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year-old-pleasant man history of HIV with recent CD4 count
322 and NASH/Etoh induced cirrhosis with history of hemorrhagic shock from
massive diverticular bleed required partial colectomy with colostomy ___
now presenting with bright red blood in ostomy bag for 5 days.// ?eval for
parastomal varices and active GIB
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 3.4 s, 53.7 cm; CTDIvol = 3.9 mGy (Body) DLP = 206.7
mGy-cm.
2) Spiral Acquisition 4.1 s, 53.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 787.4
mGy-cm.
3) Spiral Acquisition 4.1 s, 53.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 787.4
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.6 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 1,791 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries. The proximal SMA is partially
thrombosed, seen on prior.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver contour is nodular, in keeping with known cirrhosis.
It is hypoattenuating throughout suggesting fatty Liver. There is no evidence
of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Multiple portosystemic collaterals and esophageal varices are
again demonstrated. 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 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: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Patient is status post left hemicolectomy with
diverting colostomy in the left mid abdomen (303; 77). No peristomal varices
are noted. No evidence of active intrapulmonary bleeding. A well
circumscribed 3 cm lesion is noted in the right lower quadrant and AP
additional 2.5 cm in the right mid abdomen could represent too walled-off old
blood. Extensive diverticulosis is noted throughout colon. 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.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of active arterial extravasation. No evidence of parastomal
varices.
2. 2 well-circumscribed intra-abdominal lesions measuring 3 cm and 2.5 cm
likely represent fluid collections with old hemoperitoneum.
3. Cirrhotic Liver.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR, Weakness
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 99.1
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 125.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ year-old-pleasant man history of HIV with recent CD4 count
322 and NASH/Etoh induced cirrhosis with history of hemorrhagic
shock from massive diverticular bleed required partial colectomy
with colostomy ___ now presenting with bright red blood in
ostomy bag for 5 days with no evidence of active bleed on EGD or
CTA A/P. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
Monitoring after bowel obstruction in setting of elevated INR
and recent Stent (___) requiring pt to remain on ASA/plavix
.
History of Present Illness:
___ w/ CAD s/p CABG with recent SVG-PDA BMS placed on ___, sCHF
(EF 30% with ICD since ___, restrictive lung disease with
history of asbestos exposoure, p/w chest pain, nausea, vomiting,
abdominal pain.
Pt stated that his pain started yesterday (___) evening. The
pain was ___, pressure over left sternum, associated with
abdominal pain, nausea and vomiting - lasted all night. Had seen
PCP, ___ that day and was okay, although feeling
slightly off all day. Pt also had three grey loose stool last
night. Didn't have any nausaea or abdominal pain until it
developed suddenly at night. Threy up evening meds (which
according to his wife include his ASA/plavix).
At baseline, pt has chronic SOB with limited ambulation capacity
within the room. He also c/o ___ days cough before this
presentation. On ROS, Denies diarrhea or constipation. Denies
history of prior bowel surgeries. No HA, lightheadedness,
dizziness.
Of note, pt had recent PCI by Dr. ___ on ___, with BMS placed in
SVG-RPDA. Pt had patent LIMA-CAD, SVD-D, and occluded SVG-OM.
In the ED, initial VS were: 98.6 64 135/68 16 97%. In the ED, pt
c/t have ___ chest pain, not responding to nitro sl (1 tab)
and morphine (5mg IV) and dilaudid 1mg IV. Cards saw in ED and
in setting of no EKG changes, neg trops x 2, evidence of bowel
obstruction thought said no concern ACS. Rec continuing
ASA/Plavix due to recent BMS. Dr. ___. Significant
improvement in abd pain after NG placement with nasty NGT output
after placement. CT abdomen showed strange duodenal volvulus in
part that cannot volvulize -> surg atd more likely obstructive
mass -> need EGD with possible bipsies (GI happy to do once
coagulopathy corrected - want INR < 2, prefer < 1.7). Would only
go to OR for surgery in emergency without diagnosis. Got 2 units
FFP and 10mg IV Vit K. Since was somewhat confused in the ED and
had high INR, head CT done to r/o bleed - no acute changes.
Evidence of vascular disease. VS okay, mid ___ on RA
On arrival to the MICU, feels much better after NGT placement.
No longer nauseated and no abdominal pain. Doesn't feel
confused. No chest pain. Breathing fine.
Past Medical History:
- CAD s/p anterior and inferior MIs s/p CABG ___
- Ischemic Cardiomyopathy and CHF ___ EF 28%) s/p ICD in
___
- Afib on warfarin
- PACING/ICD: dual chamber ICD ___
- s/p bilateral carotid endarterectomy
- Diabetes
- Dyslipidemia
- Hypertension
- h/o Frontal lobe CVA
- Restrictive lung disease (asbestos exposure)
- Obstructive sleep apnea on CPAP
- h/o PUD
- Benign abdominal tumor s/p resection
- Restless leg syndrome
- Depression on lamotrigine
- Prostate cancer, s/p radiation, c/b radiation proctitis
- Gout
- Arthritis
Social History:
___
Family History:
Maternal aunt may have had Alzheimer's disease. Father died of
complications related to a ___ injury at a young age.
Mother lived to be ___ and died following a rapidly progressive
course of pancreatic cancer. One sister died in early ___
possibly related to malnutrition. 4 adult siblings are all in
good health. Brother HTN.
Physical Exam:
Admission exam:
General: Alert and oriented x 3 with no distress
HEENT: Sclera anicteric, dry MM, OP clear, NGT in place
Neck: supple
CV: IRIR, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal deficits, some odd comments during interview but
seemed to generally understand what is going on and why in
hospital
Discharge Exam:
General: AAOx3, in NAD
HEENT: MMM, neck supple
CV: Irregularly irregular, no MRG
Lungs: CTAB
Abd: Soft, nontender, nondistended normoacive bowel sounds, no
rebound or guarding
Ext: Warm well perfused. 2+ pulses bilaterally
Pertinent Results:
Admission labs:
___ 09:50AM BLOOD WBC-8.7 RBC-4.00* Hgb-9.6* Hct-33.2*
MCV-83 MCH-24.1* MCHC-29.0* RDW-22.2* Plt ___
___ 09:50AM BLOOD Neuts-80.7* Lymphs-10.7* Monos-8.3
Eos-0.3 Baso-0.1
___ 09:50AM BLOOD ___ PTT-60.3* ___
___ 09:50AM BLOOD Glucose-212* UreaN-23* Creat-0.9 Na-139
K-3.3 Cl-104 HCO3-24 AnGap-14
___ 09:50AM BLOOD ALT-46* AST-27 CK(CPK)-49 AlkPhos-89
TotBili-0.4
___ 11:58AM BLOOD Lactate-1.9
Discharge labs:
___ 08:00AM BLOOD WBC-8.1 RBC-3.58* Hgb-8.6* Hct-30.1*
MCV-84 MCH-24.0* MCHC-28.6* RDW-22.2* Plt ___
___ 08:00AM BLOOD ___ PTT-29.7 ___
___ 08:00AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
___ 08:00AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
CT Head W/O Contrast -- Preliminary Result+ Dictated (___)
No ICH. CHronic bifrontal encephalomalcia and microvasc dz.
CT Abd & Pelvis With Contrast -- Preliminary Result:
Marked stomach distension with twisting of the duodenal bulb,
concerning for early developing midgut volvulus (possibly ___
surgical adhesions). Distal bowel is fluid filled with areas of
wall edema and hyperenhancement-could be reactive vs. unerlying
GI infection/inflammation. Markedly distended GB and new mild
diffuse bil dil- ?related to partial CBD obstruction at site of
volvulus. No specific signs for acute cholecystitis, correlate
clinically.
Chest (Pa & Lat)
Preliminary Report: Mild interstitial edema with small bilateral
effusions.
EKG: Afib, rate controlled, abnormal conduction with some PCVs,
no significant change from prior, no ST changes.
Medications on Admission:
1. citalopram 20 mg daily
2. insulin lispro ISS
3. docusate sodium 100 BID
4. nitroglycerin 0.4 mg Tablet SL PRN
5. warfarin 2 mg Tablet daily
6. acetaminophen 500-1000mg TID PRN pain
7. lamotrigine 400mg daily
8. simvastatin 20 mg daily
9. ranolazine 1,000 mg Tablet Extended Release BID
10. aspirin 325 mg Tablet daily
11. isosorbide mononitrate 90 mg Tablet Extended Release 24 hr
12. simethicone 80 mg Tablet, QID PRN gas/bloating
13. clopidogrel 75 mg Tablet daily
14. metoprolol tartrate 100 mg Tablet BID
15. furosemide 40 mg Tablet daily
16. Flomax 0.4 mg Capsule, Ext Release 24 hr
17. Seroquel 25 mg Tablet Qhs
18. Seroquel 25 mg Tablet Qhs PRN agitation
19. lisinopril 2.5 mg Tablet daily
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
5. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: do not exceed 3 g in 24 hour period.
7. lamotrigine 200 mg Tablet Sig: Two (2) Tablet PO once a day.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Outpatient Lab Work
Please check INR on ___ and have results faxed to Dr.
___ (or discussed over the phone).
___. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
14. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for indigestion.
15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
16. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
19. Seroquel 25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation.
20. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Duodenal Ulcer
Secondary: CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with coronary artery disease post-stenting, new
abdominal pain and guarding.
___.
TECHNIQUE: Helical MDCT images were acquired from the lung bases through the
greater trochanters following the uneventful administration of 130 cc of
intravenous Omnipaque. 5-mm axial, sagittal, and coronal multiplanar
reformats were created.
FINDINGS: Again seen are calcified pleural plaques in the right hemithorax,
with persistent rounded atelectasis in the right lower lobe. No pleural
effusions are present.
ABDOMEN: Liver enhances homogeneously on this single phase examination.
Gallbladder is newly distended, though without calcified stones, wall edema,
fat stranding, or pericholecystic fluid. There is mild periportal edema.
Pancreas is mildly fatty replaced, without ductal dilation. Slight prominence
of the biliary system is unchanged from prior examination. The spleen is
normal in size, with accessory splenule anterior to the inter -pole.
The adrenals are normal. Kidneys enhance and excrete contrast promptly and
symmetrically, without masses or hydronephrosis. Stable renal hypodensities
are too small to characterize, and likely represent cysts.
Stomach has become massively dilated, with internal air-fluid level. There is
a relative transition point in the second portion of the duodenum, which
demonstrates mild mucosal thickening and hyperenhancement. Surrounding
mesenteric swirling and fat stranding (2:33, 601B:30). Prominent celiac nodes
and 13-mm periportal lymph node. The distal small bowel is fluid filled, but
normal in caliber.
PELVIS: Changes of right colectomy are present, with transverse ileocolostomy
in the right upper quadrant. No evidence of leak or obstruction. Transverse
colon is fluid filled. Descending and sigmoid colon are collapsed.
Foley catheter is present in the bladder. Brachytherapy seeds are noted in
the prostate.
Trace free pelvic fluid is unchanged. There is no pneumatosis,
pneumoperitoneum, or portal/mesenteric venous gas.
Dense calcifications and atheromatous plaques throughout the abdominal aorta
and branch arteries. Retroperitoneal lymph nodes again measure up to 12 mm in
the left paraaortic region and 6 mm in the aortocaval region.
Severe multilevel degenerative changes in the spine, with bridging anterior
osteophytes. There is lumbar facet hypertrophy and ligamentum flavum
thickening. Prominent disc-osteophyte complexes at L4-5 and L5-S1 indent the
ventral thecal sac.
IMPRESSION:
1. Gastric outlet obstruction secondary to abnormality in the second portion
of the duodenum. This is most consistent with inflammatory stricture, as a CT
3 weeks ago did not show an abnormality in this region. Duodenal carcinoma
seems less likely. Recommend endoscopy.
2. Distended gallbladder, without specific signs of acute cholecystitis.
Radiology Report
INDICATION: ___ male with coronary artery disease, post-stenting on
Coumadin, INR of 7, now with altered mental status; evaluate for intracranial
hemorrhage.
COMPARISON: NECT, ___.
TECHNIQUE: Contiguous non-contrast axial images were obtained through the
brain and reconstructed at 5-mm intervals. 2-mm coronal and sagittal
multiplanar reformats are also created.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or
vascular territorial infarct. The ventricles and sulci are prominent, as
before, compatible with age-related atrophy. Again noted are foci of
encephalomalacia in left and inferior right frontal lobes, suggestive of prior
trauma. There is no shift of the normally midline structures. Dense
calcifications in the cavernous carotid arteries. The visualized paranasal
sinuses are well aerated. The mastoid air cells and middle ear cavities are
clear. The orbits and intraconal structures are symmetric and unremarkable.
IMPRESSION: No acute hemorrhage. Bifrontal cystic encephalomalacia, as
before.
NOTE ADDED IN ATTENDING REVIEW: The bifrontal encephalomalacic foci are in
sites more typical of cortical/subcortical infarction, than of post-traumatic
contusion. Moreover, on the MR examination of ___, they demonstrate only
corresponding FLAIR-hyperintensity, presumably gliosis, with no susceptibility
artifact on the GRE sequence, making remote contusion even less likely.
Radiology Report
AP CHEST, 4:54 AM, ___
HISTORY: ___ man with bowel obstruction. Replaced nasogastric tube.
Evaluate placement.
IMPRESSION: AP chest compared to ___:
Nasogastric tube ends in the upper stomach. Mild cardiomegaly unchanged.
Pulmonary vascular engorgement is chronic, but there is probably no pulmonary
edema. Bilateral pleural thickening is largely calcified. No pneumothorax.
Transvenous right atrial pacer and right ventricular pacer defibrillator leads
in their standard placements, unchanged.
Radiology Report
AP CHEST, 3:03 P.M., ___
HISTORY: New nasogastric tube, confirm placement.
IMPRESSION: AP chest compared to ___ and ___ at 4:54 a.m.:
Nasogastric tube as seen on the enhanced view ends in the upper stomach.
Moderate cardiomegaly and extensive pleural thickening and calcification are
chronic. Currently, there is no pulmonary edema and pulmonary vascular
engorgement is relatively mild. Transvenous right atrial and right
ventricular pacer leads are in standard placements.
Radiology Report
REASON FOR EXAMINATION: Duodenal ulcer and gastric outlet obstruction after
ET tube placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
NG tube tip is at the mid stomach and should be further advanced. Pacemaker
leads are unremarkable. Mediastinum is stable. Lungs are essentially clear
except for bilateral pleural effusions. No pneumothorax is seen.
A subsequent study has demonstrated advanced NG tube terminating in the
stomach.
Radiology Report
REASON FOR EXAMINATION: NG tube advancement.
Ap radiograph of the chest
As compared to prior study obtained the same day earlier, the NG tube has been
advanced, terminating in the stomach. Otherwise, no changes have been seen.
Radiology Report
INDICATION: ___ male with chest pain and recent stent placement.
Evaluate for CHF or widened mediastinum.
COMPARISON: Multiple chest radiographs, the latest from ___ and the
earliest from ___.
TWO VIEWS OF THE CHEST: The lungs are well expanded and show mild interstitial
opacities. The cardiac silhouette is enlarged. The mediastinal silhouette is
normal. There are small bilateral pleural effusions, unchanged. A left-sided
pacer terminates with leads in the right atrium and right ventricle. Sternal
wires are intact and mediastinal clips are unchanged.
IMPRESSION: Mild interstitial edema with small bilateral effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CP N/V/D
Diagnosed with INTESTINAL OBSTRUCT NOS, CHEST PAIN NOS, ABDOMINAL PAIN RUQ, ATRIAL FIBRILLATION, CARDIAC PACEMAKER STATUS
temperature: 98.6
heartrate: 64.0
resprate: 16.0
o2sat: 97.0
sbp: 135.0
dbp: 68.0
level of pain: 6
level of acuity: 2.0 | ___ M w/ PMH significant for A.fib (on Coumadin), presumed ILD,
severe CAD (s/p 4V CABG), ischemic cardiomyopathy with an LVEF
of 25% presenting with bowel obstruction due to duodenal
volvulus due to hematoma, inflammatory cause, stricture, or
mass, also w/ supratherapeutic INR.
# Bowel Obstruction: Symptoms initially of N/V/Abd pain. Pt had
area of duodenal inflammation on CT scan and surgery was
originally consulted who did not think he required a surgical
intervention. an NG tube was placed and he had a large amount of
nonbloody noncoffee ground gastric contents were suctioned out.
He was made NPO and watched overnight. GI was consulted who
performed an EGD which showed 2 duodenal ulcers but with some
edema around the ampula. While ther was edema near the pylorius
the EGD socope was easily passed through and therefore not an
obstruction. The patient had decreased output from his NGT and
it was pulled on HD #3. His diet was slowly advanced and he was
tolerating a normal diet at the time of discharge. He denied
any further abodminal pain.
-Started omeprazole 40mg po BID
-Pt will require repeat EGD in ___ (to be scheduled by the
patient)
-Patient should avoid NSAIDs and alcohol
# CAD with recent Stents: Patient with significant CAD with
situation further complicated by new BMS on ___. High risk
for occlusion of stents if misses meds. He had one episode of
chest pain that resolved without intervention within 5 minutes
and had no EKG changes. He was maintained on his outpatient
plavix and aspirin even when he had his NGT in place for concern
about restenosis of his recent stent.
-No changes made to regimen
# Ischemic Cardiomyopathy and CHF ___ EF 28%) s/p ICD in |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iv contrast
Attending: ___.
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Pacemaker placement ___
History of Present Illness:
___ with CHFpEF, hypertension, paroxysmal atrial fibrillation on
rate control and warfarin who presents with a week of malaise,
lightheadedness, nausea and vomiting now transferred to the CCU
for concern for complete heart block.
Per review of OMR, she was noted to be feeling poorly
approximately 1 week prior to presentation. She was noted at
this time to have heart rates in the ___ with SBP 140s-160s.
Subsequent reports in the record show increased heart rates in
the ___, which per OMR is an often noted heart rate. She
presented for evaluation to the ED given persistent symptoms and
acute worsening of her lightheadedness.
In the ED, initial vitals were: pain 2 HR 32 125/43 16 97% RA
Labs: INR 3.4, WBC 10.3 with 73%N, H/H 10.6/32.9
Exam was notable for cold extremities which later improved with
initiation of dopamine.
Imaging: CXR with no acute process
Consults: cardiology
Patient was given: dopamine 5 mcg/kg/min, increased to 10 with
increase in BP and heart rate as well as return to sinus rhythm,
and relative hyperkalemia managed with calcium, insulin, glucose
Decision was made to admit to CCU for further monitoring on
dopamine gtt and reassessment regarding possible need of pacer
wire.
Vitals on transfer were: 98.0 72 158/44 16 RA
On the floor, patient reports that her lightheadedness has
improved. She has mild chest pain that is baseline for her. She
is breathing comfortably on room air.
Of note, the patient was weaned down to dopamine of 3mg upon
transfer with HRs in ___.
Past Medical History:
- h/o Urosepsis
- ILD (possibly ___ amiodarone)
- HTN
- dCHF
- Atrial Fibrillation (dx ___
- Spinal Stenosis
- Hematochezia (Internal Hemorrhoids on ___ from ___
- Gastritis (from EGD in ___
- Osteoporosis
- Peptic Ulcer Disease
- Vertigo
- chronic L sided back pain
Social History:
___
Family History:
Father: CAD
Mother: CVA
Brothers: CAD
___ history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 151/92 73 17 95%RA
Tele: NSR with rates in ___
Gen: Laying comfortably in bed, NAD
HEENT: NC/AT, EOMI, PERRL
NECK: Supple, no elevated JVP
CV: Regular rate, +S1/S2, no m/r/g
LUNGS: CTAB, no w/r/r, speaking in full sentences, no increased
WOB
ABD: Soft, NTTP, ND, +BS
EXT: Warm and dry. 2+ pitting edema to the knees
NEURO: CN II-XII grossly intact, AAOx3,
DISCHARGE PHYSICAL EXAM:
VS: Tmax/Tcurrent: 98.2/98.4 HR: 60s RR: 16 BP: 123-166/40-60
(146/59) O2 sat: 97% RA
I/O: 24h 1455/1475 (-20mL); MN 50/325 (-275)
Weight: 61.8 kg
Tele: No alarms. Paced, sinus rhythm.
Exam:
Gen: Sleeping comfortably in bed, NAD
HEENT: anicteric sclera, MMM
Neck: no JVD
CV: RRR, no significant m/r/g, pacer site is nontender, covered
with kerlex
Resp: CTAB without adventitious sounds
ABD: NT/ND, +BS
Extr: wwp, intact peripheral pulses
Skin: no new rash
Neuro: grossly intact, moving all four extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 08:58PM BLOOD WBC-10.3*# RBC-3.50* Hgb-10.6* Hct-32.9*
MCV-94 MCH-30.3 MCHC-32.2 RDW-12.5 RDWSD-42.8 Plt ___
___ 08:58PM BLOOD Neuts-73.1* Lymphs-14.4* Monos-9.3
Eos-1.7 Baso-0.9 Im ___ AbsNeut-7.52* AbsLymp-1.48
AbsMono-0.95* AbsEos-0.17 AbsBaso-0.09*
___ 08:58PM BLOOD ___ PTT-40.4* ___
___ 08:58PM BLOOD Glucose-200* UreaN-55* Creat-2.1* Na-132*
K-6.1* Cl-102 HCO3-18* AnGap-18
___ 08:58PM BLOOD ALT-13 AST-16 CK(CPK)-56 AlkPhos-74
TotBili-0.2
___ 08:58PM BLOOD Lipase-30
___ 08:58PM BLOOD CK-MB-2
___ 08:58PM BLOOD cTropnT-0.02*
___ 08:58PM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.1 Mg-2.2
___ 08:58PM BLOOD TSH-1.5
___ 09:54PM BLOOD K-5.9*
___ 10:03PM BLOOD Lactate-0.8 K-6.0*
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-7.3 RBC-3.65* Hgb-10.8* Hct-34.2
MCV-94 MCH-29.6 MCHC-31.6* RDW-12.2 RDWSD-42.5 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-120* UreaN-29* Creat-1.6* Na-138
K-4.6 Cl-105 HCO3-24 AnGap-14
___ 07:20AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.0
Imaging:
========
+ CXR (___):
FINDINGS:
AP portable upright view of the chest. There is no focal
consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is unchanged with normal heart size. Old left rib
deformities are again noted.
IMPRESSION:
No acute intrathoracic process
+ CXR (___):
There is a new dual lead left-sided pacemaker with intact lead
tips in the
right atrium and right ventricle. Heart size is upper limits of
normal but stable. There is coarsening of the bronchovascular
markings without overt pulmonary edema, focal consolidation, or
pleural effusions. There are no pneumothoraces.
+ EKG (___):
no p-wave activity with regular ventricular rate of 30, left
axis, LAFB, LVH by limb leads (aVL R > 11)
Repeat EKG ___ on dopamine 10 mcg/kg/min
sinus rhythm, rate ___
+ TTE (___):
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Doppler parameters are indeterminate for
left ventricular diastolic function. 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) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
severe increase in left atrium volume is no longer appreciated.
There is slightly less mitral regurgitation. Other findings are
similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. HydrALAzine 10 mg PO Q8H
4. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
5. Mirtazapine 15 mg PO HS
6. Omeprazole 20 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Torsemide 10 mg PO 3X/WEEK (___)
9. Warfarin 2 mg PO 6X/WEEK (___)
10. Warfarin 3 mg PO 1X/WEEK (MO)
11. Acetaminophen 500 mg PO Q8H:PRN pain
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
13. diclofenac sodium 1 % TOPICAL BID PRN pain
14. Diltiazem Extended-Release 240 mg PO DAILY
15. Fluocinonide 0.05% Cream 1 Appl TP BID
16. Pregabalin 25 mg PO DAILY
17. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Carvedilol 12.5 mg PO BID
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluocinonide 0.05% Cream 1 Appl TP BID
6. HydrALAzine 10 mg PO Q8H
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain
9. Pregabalin 25 mg PO DAILY
10. Warfarin 2 mg PO 6X/WEEK (___)
11. Warfarin 3 mg PO 1X/WEEK (MO)
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
13. diclofenac sodium 1 % TOPICAL BID PRN pain
14. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
15. Mirtazapine 15 mg PO HS
16. Torsemide 10 mg PO 3X/WEEK (___)
17. Cephalexin 250 mg PO Q8H Duration: 3 Doses
take 3 doses on ___ then discontinue
RX *cephalexin 250 mg 1 capsule(s) by mouth three times a day
Disp #*3 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Bradycardia secondary to sinus node arrest with
junctional escape
Secondary: Chronic congestive heart failure with persevered
ejection fraction, hypertension, atrial fibrillation,
interstitial lung disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with n/v bradycardia
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is unchanged with
top-normal heart size. Old left rib deformities are again noted.
IMPRESSION:
No acute intrathoracic process
Radiology Report
INDICATION: ___ year old woman s/p dual chamber PPM. // assess lead placement
and r/o PTx
COMPARISON: Radiographs from ___
IMPRESSION:
There is a new dual lead left-sided pacemaker with intact lead tips in the
right atrium and right ventricle. Heart size is upper limits of normal but
stable. There is coarsening of the bronchovascular markings without overt
pulmonary edema, focal consolidation, or pleural effusions. There are no
pneumothoraces.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Chest pain, Nausea, Headache
Diagnosed with Atrioventricular block, complete, Bradycardia, unspecified, Hyperkalemia, Acute kidney failure, unspecified
temperature: nan
heartrate: 32.0
resprate: 16.0
o2sat: 97.0
sbp: 125.0
dbp: 43.0
level of pain: 2
level of acuity: 1.0 | ___ with CHFpEF, hypertension, paroxysmal atrial fibrillation on
rate control and warfarin who presents with a week of malaise,
nausea and vomiting found to be bradycardic with EKG
demonstrating sinus arrest with junctional escape rhythm.
# Bradycardia: The patient presented with one week history of
lightheadedness, malaise, and nausea found to be bradycardic
with HR in the ___. Likely due to sinus node arrest with slow
junctional escape from beta blockade and CCB, given restoration
of sinus rhythm with beta agonism from dopamine. Differential
initially included complete heart block, but this was deemed as
less likely given return to sinus rhythm with the administration
of dopamine. Upon admission to the CCU, the patient's beta
blocker and calcium channel blocker were held. She was weaned
off the dopamine drip and her HR improved to 50-60's. Given
concern for sick sinus syndrome and the need for rate control
with her atrial fibrillation, the patient underwent dual chamber
___ pacemaker placement on ___ without
complications.
# Hyperkalemia: The patient's potassium was elevated to 6.1 on
admission likely secondary to potassium retention in the setting
of hypovolemia (poor PO intake with nausea/malaise) and
decreased distal sodium delivery. The patient received calcium
gluconate, insulin and dextrose in the ED. EKG consistent with
sinus node arrest with junctional escape, however, no evidence
of T wave changes. Once in the ICU, she received gentle IVF
boluses and her hyperkalemia resolved. Given her hyperkalemia,
hyponatremia and bradycardia upon admission, a morning cortisol
level was checked and returned elevated at 31.1 ruling out
adrenal insufficiency. Home spironolactone held at discharge.
# Hyponatremia: The patient's sodium was 132 upon admission
likely hypovolemic hyponatremia in the setting of poor PO
intake. Resolved with the administration of IVF.
# CHFpEF: Echo from ___ demonstrated mild dilatation of left
atrium with normal thickness of LV and systolic function
(LVEF>55%). The patient's torsemide and spironolactone were held
upon admission given hyperkalemia, dehydration and ___. Her
daily weights and I/O's were monitored closely and there was no
sign of acute decompensation during her hospitalization.
Restarted home carvedilol and torsemide upon discharge. Given
her initial presentation with hyperkalemia, the spironolactone
was discontinued.
# Paroxysmal atrial fibrillation: Rate controlled with diltiazem
and carvedilol and on anticoagulation with Warfarin for
CHADs-Vasc=5. The BB and CCB were initially held in the setting
of bradycardia and sinus node arrest later resumed following
pacemaker placement. Her warfarin was held for her procedure but
resumed ___.
# Hypertension: The patient was hypertensive to SBPs 190-200s on
the day of admission and intermittently throughout her hospital
stay. She was continued on her home hydralazine and restarted on
the carvedilol and diltiazem following pacemaker placement with
improvement of SBPs to 110-130s upon discharge.
#Acute on chronic kidney injury:Cr 2.1 on admission which is
mildly elevated from baseline ~1.8. Likely pre-renal in the
setting of poor PO intake and vomiting. Resolved with IVF.
# Leukocytosis: Likely secondary to stress response. Patient
afebrile with no systemic signs/symptoms of infection. Resolved
without intervention.
CHRONIC ISSUES:
================
#Iron deficiency anemia: The patient's HgB 10.6 on admission
which is stable from her most recent baseline. No active signs
of bleeding during hospitalization. Consider further work-up as
an out-patient.
#Spinal stenosis: Given Tylenol and oxycodone prn for pain
#Osteoporosis: Continued home vitamin D. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
worsening headache, fever and nausea/vomiting.
Major Surgical or Invasive Procedure:
1. Removal of deep abscess, lumbar.
2. Incision and debridement, lumbar wound.
3. Revision, cerebral spinal fluid leak repair.
History of Present Illness:
The patient is a ___ male with history of L5-S1 disc
herniation s/p L5-S1 microdiscectomy ___ years ago with
recurrent severe S1 radiculopathy refractory to ___ and
medications, now s/p revision right L5-S1 hemilaminotomy on
___ c/b intraoperative dural tear with repair who presents
with worsening headache, fever and nausea/vomiting. The patient
was in his usual state of health until the afternoon prior to
admission when he developed worsening low back pain over his
surgical incision. He denied any new trauma or inciting event.
He denied drainage from the incision. The patient subsequently
developed a headache which worsened throughout the night. At
3:00AM on the day of admission, the patient became extremely
nauseous and developed intractable vomiting. His headache was
severe and accompanied by photophobia and phonophobia.
Temperature taken at home at that time was ___. He presented to
the ED for further evaluation. He denied any numbness,
paresthesias or weakness of the extremities. He denied bowel or
bladder incontinence. He denied chest pain, SOB, diarrhea or
changes in vision.
Past Medical History:
-Bipolar disorder.
-Prior discectomy at L5-S1 in ___
-Hernia operation in ___ and ___
-knee arthroscopy in ___ and ___
Social History:
___
Family History:
Significant for carcinoma in his mother and also lung disease in
his father.
Physical Exam:
AVSS
NAD, AOx3
Back incision without erythema or drainge; sutures intact
BLE ___ ___. SILT. WWP
Pertinent Results:
___ 04:27AM BLOOD WBC-7.9 RBC-3.83* Hgb-12.9* Hct-35.9*
MCV-94 MCH-33.6* MCHC-35.9* RDW-11.7 Plt ___
___ 06:30AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.6* Hct-34.6*
MCV-96 MCH-32.1* MCHC-33.5 RDW-12.0 Plt ___
___ 04:27AM BLOOD Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:08AM BLOOD Glucose-118* UreaN-6 Creat-0.8 Na-134
K-3.7 Cl-97 HCO3-30 AnGap-11
___ 04:27AM BLOOD Glucose-86 UreaN-5* Creat-0.6 Na-140
K-3.6 Cl-92* HCO3-34* AnGap-18
___ 10:47AM BLOOD ALT-28 AST-25
___ 06:08AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
___ 06:30AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.6
___ 06:00AM BLOOD CRP-139.8*
___ 10:15AM BLOOD CRP-118.7*
___ 10:41AM BLOOD Lactate-1.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO Q6H:PRN muscle spasms
2. Docusate Sodium 100 mg PO BID
3. Escitalopram Oxalate 20 mg PO DAILY
4. Gabapentin 300 mg PO HS
5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN pain
6. LaMOTrigine 200 mg PO BID
Discharge Medications:
1. Diazepam 5 mg PO Q6H:PRN muscle spasms
RX *diazepam 5 mg 1 tab by mouth every six (6) hours Disp #*50
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 #*100 Capsule Refills:*0
3. Escitalopram Oxalate 20 mg PO DAILY
4. Gabapentin 300 mg PO HS
5. LaMOTrigine 200 mg PO BID
6. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
breakthrough pain
RX *hydrocodone-acetaminophen 7.5 mg-325 mg ___ tablet(s) by
mouth q4-6h Disp #*100 Tablet Refills:*0
7. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every
four (4) hours Disp #*192 Unit Refills:*0
8. Naproxen 500 mg PO Q12H
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth twice a day
Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Confirmed persistent cerebral spinal fluid leak.
2. Possible lumbar wound infection.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LUMBAR SPINE MRI WITH AND WITHOUT CONTRAST
INDICATION: ___ year old man with L5-S1 laminectomy ___ years ago, now with
recurrent disc herniation, status post revision right L5-S1 hemilaminotomy on
___, complicated by intraoperative dural tear. Patient presents with
signs of meningitis. Evaluate for osteomyelitis, abscess, or other infectious
process of the spine.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and STIR images of the lumbar
spine with axial T1 and T2 weighted images. Following intravenous gadolinium
administration, sagittal and axial T1 weighted images were obtained.
COMPARISON: Lumbar spine MRI with and without contrast performed at ___
MRI on ___. Lumbar spine radiographs performed here on ___.
FINDINGS:
There is a right hemilaminectomy at L5. The previously noted large right
paracentral disc herniation at L5-S1 has been partially resected, with
enhancing granulation tissue in its place. However, there is a nonenhancing
low signal structure at the site of the disk herniation, measuring 10 mm
transverse by 4 mm AP by 12 mm craniocaudad on images 12:21 and 10:13,
suggesting a residual or recurrent disc herniation. There is a fluid
collection in the right L5 laminectomy bed, measuring 2.2 x 2.2 x 4.4 cm
(transverse x AP x craniocaudad), which has a large area of surface contact
with the thecal sac, suggesting a pseudomeningocele in the setting of the
reported history of dural tear. There is a thin tract of fluid from the
superficial aspect of the collection into the subcutaneous fat to the skin
surface, image 12:22. This collection does not demonstrate rim enhancement.
The thecal sac remains displaced posteriorly at L5-S1 and mildly compressed.
The enhancing granulation tissue in the anterior right epidural space at L5-S1
encases the traversing right S1 nerve root. The neural foramina at L5-S1 are
severely narrowed by a disc bulge and facet arthropathy with impingement of
bilateral exiting L5 nerve roots.
The nerve roots within the thecal sac demonstrate diffuse low-level contrast
enhancement in and mild clumping, suggestive of arachnoiditis. The conus
medullaris terminates at L1 and appears unremarkable.
Vertebral body heights are preserved. Alignment is normal. There are extensive
___ type 2 discogenic bone marrow changes in the endplates at L5-S1 with
high signal on T1 and T2 weighted images and signal suppression on fat
suppressed T2 weighted images, unchanged compared to ___. No
specific evidence for discitis or osteomyelitis is seen.
At T11-12, there is a small right paracentral disc protrusion which mildly
indents the right ventral surface of the spinal cord. However, the spinal
canal is not significantly narrowed, and the spinal cord remains surrounded by
plentiful cerebrospinal fluid laterally and posteriorly.
No significant abnormalities is seen from T12-L1 through L3-4.
At L4-5, there is a disc bulge and moderate bilateral facet arthropathy.
Subarticular zones are narrowed but traversing L5 nerve roots do not appear
compressed. There is moderate-to-severe right and severe left neural foraminal
narrowing with impingement of bilateral exiting L4 nerve roots.
IMPRESSION:
1. Residual or recurrent right paracentral disc herniation at L5-S1, 10 x 4 x
12 mm, smaller than the pre-existing disc herniation seen on ___.
2. Fluid collection in the right L5 laminectomy bed with a large area of
surface contact with the thecal sac, suggesting a pseudomeningocele in the
setting of the reported dural tear. The collection extends to the skin
surface. There is no rim enhancement to clearly indicate superimposed
infection, though infection cannot be definitively excluded by imaging.
3. Clumping and diffuse contrast enhancement of the nerve roots within the
thecal sac, suggesting arachnoiditis.
4. At L5-S1, the thecal sac remains displaced posteriorly and mildly
compressed. Enhancing granulation tissue encases the traversing right S1 nerve
root. Bilateral exiting L5 nerve roots are impinged as the L5-S1 neural
foramina are severely narrowed by disc bulge and facet osteophytes. L4-5
neural foramina are also moderately to severely narrowed with impingement of
bilateral exiting L4 nerve roots.
NOTIFICATION: The following preliminary report was discussed with Dr. ___
by Dr. ___ via telephone on ___ at 11:45 ___, 5 minutes after
discovery of the findings: "Small fluid collection at the L5-S1
hemilaminectomy site, could reflect a postsurgical collection such as a
hematoma or seroma. An underlying infectious process cannot be entirely
excluded. No discitis, osteomyelitis or epidural abscess." Additional findings
in impression items #1 and #2 were discussed by Dr. ___ Dr. ___ by
telephone at approximately 8:45 am on ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ s/p revision L5-S1 hemilaminotomy (___) c/b dural tear s/p
repair p/wincreasing HA, photophobia, phonophobia, N/V and fever now s/p I D,
repair ofdural leak ___. // increasing headaches
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 891.9 mGy-cm
CTDI: 53.59.
COMPARISON: None
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction.
The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The visualized bony structures are grossly unremarkable.
There is some very minimal mucosal thickening of the anterior ethmoid air
cells. The remainder of the paranasal sinuses are clear. The mastoid air cells
and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
INDICATION: New left PICC placement, here to evaluate PICC position.
COMPARISON: No prior studies available.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: A left PICC has been placed with the tip over the low SVC. The
course of the line is unremarkable. There is no pneumothorax or pleural
effusion. The lungs are clear. The cardiomediastinal and hilar contours are
within normal limits.
IMPRESSION:
Left PICC ending in the low SVC.
NOTIFICATION: Findings were communicated by Dr. ___ to IV nurse ___
via pager at 11 a.m. on ___.
Radiology Report
STUDY: Lumbosacral ___.
CLINICAL HISTORY: Patient with L5-S1 hemilaminectomy. Evaluate for fracture.
FINDINGS: Comparison is made to prior radiographs from ___.
There are five non-rib-bearing lumbar-type vertebral bodies. There are
degenerative changes with loss of intervertebral disc height, worse at L4-L5,
which appears stable since the previous study. Degenerative changes of the
lower facet joints also present. There is no abnormal ___- or
retrolisthesis. Surgical clips are seen in the left hemipelvis. There are
minimal degenerative changes and spurring of the superolateral aspects of
bilateral acetabuli.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with MENINGITIS NOS
temperature: 102.8
heartrate: 107.0
resprate: 16.0
o2sat: 95.0
sbp: 107.0
dbp: 45.0
level of pain: 10
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued throughout his hospitalization for treatment of his
spinal abscess and CSF leak. Initial postop pain was controlled
with a PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed and he was successfully voiding. The patients
mobilization status was slowly advanced as he tolerated. He
successfully ambulated with Nursing for mobilization OOB.
Infectious Disease and Chronic Pain were consulted and advised
with management of his antibiotics and pain medications
respectively. Hospital course was otherwise unremarkable.On the
day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet and without headache, photophobia, phonophobia, fever,
nausea, or vomiting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / erythromycin base
Attending: ___.
Chief Complaint:
cough, abnormal labs
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of chronic
right arm pain, who is presenting today after referral for
inequivocal TB testing.
Patient reports that over the past ___ months, he has been
having increasing right arm / hand pain that then occurred in
the setting of a back injury while at work. He continued to have
right arm pain, usually at nighttime, and this then worsened and
started to occur during the day time. He builds homes for a
living, and therefore had some difficulties and was referred to
a chronic pain specialist and underwent multiple back injections
etc., and now is on acupuncture. Given increasing right arm
pain, numbness/tingling in his right hand ___ fingers), his
PCP then ordered an MRI of his right shoulder which showed
concerning lung findings 4 days prior.
Over the past 4 days, he has now undergone a MRI of his right
shoulder, a CT scan of his chest, and a ___ was
interdeterminate. Patient notably has no cough at this time,
however reports that about 4 months ago had a URI which had
scant hemoptysis, however no hemoptysis now. No fevers,
nightsweats, or coughing, or weight changes. Patient has never
been incarcerated, but does have exposure to criminals most
recently in ___ in work program. He denies any chest pains,
palpitations, or shortness of breath. He has been tested in the
past for HIV, which has been negative.
Patient's mother passed away from pulmonary fibrosis when she
was ___. Patient reports no other family history of pulmonary
diseases. He does continue to work in ___, and reports
not wearing a mask on the job. He denies any specific exposures
to asbestosis, however does cut PVC pipes and this leads to
powder formation which he does inhale.
In the ED, initial vital signs were: 96.8 68 133/86 18 100% RA.
Pulmonary was consulted for further evaluation of GGOs.
Patient's labs unremarkable, and had 2 sputums obtained prior to
arrival to the floor.
Vitals prior to transfer were: 4 97.8 74 128/74 16 98% RA
Upon arrival to the floor, patient reports no acute complaints.
Past Medical History:
1. Former alcohol abuse s/p detoxification now in recovery x
___
2. Multiple traumas to the digits, with table saw on third
finger
3. Former tobacco abuse (up to 2 ppd x ___
Social History:
___
Family History:
Mother died at ___ of pulmonary fibrosis. Father is alive at ___.
Two sisters, one brother alive and well, no other particular
family history.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 122/81, HR 84, Afebrile, 99% on RA.
General: Well appearing, no acute distress.
HEENT: NC/AT. No cervical lymphadenopathy appreciated. No
conjunctival pallor or scleral icterus.
Neck: No thyromegaly appreciated, no JVD.
Cardiac: RRR, S1, S2. no extra sounds heard.
Lungs: CTAB/L. No adventitial sounds heard.
Abdomen: Soft, NT/ND. +BS.
Extremities: warm, well perfused. No ___ edema bilaterally. Full
range of motion in the right shoulder, with some sensation
changes at fingertips however grossly intact.
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
Skin: Mild excoriations 1 x 1 cm on lower leg.
DISCHARGE EXAM
==============
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated
Lungs: lungs CTAB, no w/r/c
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: Patient has a positive "empty can test" on the right and
has pain in shoulder with abduction against resistance at 90
degrees. Diminished biceps size versus left biceps. Otherwise
warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Skin: Without rashes or lesions
Neuro: CN II-XII intact, ___ strength throughout, normal
sensation
Pertinent Results:
ADMISSION LABS
==============
___ 08:02AM BLOOD WBC-5.8 RBC-4.14* Hgb-11.4* Hct-36.7*
MCV-89 MCH-27.5 MCHC-31.1* RDW-12.8 RDWSD-41.7 Plt ___
___ 08:02AM BLOOD Neuts-57.7 ___ Monos-8.5 Eos-1.4
Baso-0.5 Im ___ AbsNeut-3.33 AbsLymp-1.81 AbsMono-0.49
AbsEos-0.08 AbsBaso-0.03
___ 08:02AM BLOOD ___ PTT-29.2 ___
___ 08:02AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-99 HCO3-31 AnGap-13
___ 08:02AM BLOOD ALT-17 AST-18 LD(LDH)-193 AlkPhos-64
TotBili-0.2
___ 08:02AM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.3 Mg-1.6
PERTINENT LABS
==============
___ 08:00AM BLOOD calTIBC-246* Ferritn-227 TRF-189*
___ 08:00AM BLOOD ___
___ 08:00AM BLOOD RheuFac-8 CRP-17.8*
___ 08:00AM BLOOD ANCA-NEGATIVE B
___ 08:00AM BLOOD HIV Ab-Negative
DISCHARGE LABS
==============
___ 07:42AM BLOOD WBC-5.0 RBC-4.71 Hgb-13.2* Hct-40.9
MCV-87 MCH-28.0 MCHC-32.3 RDW-12.7 RDWSD-40.3 Plt ___
___ 07:42AM BLOOD Plt ___
___ 07:42AM BLOOD Glucose-84 UreaN-16 Creat-0.7 Na-137
K-4.4 Cl-97 HCO3-31 AnGap-13
___ 07:42AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0
IMAGING
=======
CXR PA & LAT ___
IMPRESSION:
No acute cardiopulmonary process. Right upper lobe opacity has
resolved.
MICROBIOLOGY
============
___ test for Pneumocystis jirovecii
(carinii) NEGATIVE
___ URINE ACID FAST CULTURE-PENDING
___ URINE Chlamydia trachomatis, Nucleic Acid Probe,
with Amplification-NEGATIVE; NEISSERIA GONORRHOEAE (GC), NUCLEIC
ACID PROBE, WITH AMPLIFICATION-NEGATIVE
___ SPUTUM GRAM STAIN-CONTAMINATED; RESPIRATORY
CULTURE- CONTAMINATED; ACID FAST CULTURE-PRELIMINARY; ACID FAST
SMEAR-NEGATIVE; Immunoflourescent test for Pneumocystis
jirovecii (carinii)- QUANTITY NOT SUFFICIENT
___ BLOOD CULTURE PENDING
SPUTUM GRAM STAIN-CONTAMINATED; RESPIRATORY
CULTURE-CONTAMINATED; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; MTB Direct Amplification-PRELIMINARY
___ SPUTUM ACID FAST SMEAR-NEGATIVE; ACID FAST
CULTURE-PRELIMINARY
___ SPUTUM GRAM STAIN-CONTAMINATED; RESPIRATORY
CULTURE-CONTAMINATED; ACID FAST SMEAR-NEGATIVE; ACID FAST
CULTURE-PRELIMINARY
___ URINE URINE CULTURE- SKIN CONTAMINATION
___ BLOOD CULTURE PENDING
___ BLOOD CULTURE PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 50 mg PO DAILY
2. Cyclobenzaprine 10 mg PO TID:PRN spasms
3. Naproxen 500 mg PO Q12H
4. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
Discharge Medications:
1. BuPROPion 50 mg PO DAILY
2. Cyclobenzaprine 10 mg PO TID:PRN spasms
3. Naproxen 500 mg PO Q12H
4. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
#abnormal lung imaging (ground glass opacities)
SECONDARY DIAGNOSES
===================
#anemia
#right arm pain
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: ___ year old man with incidental GGOs on MRI assessing right arm
pain. Any evidence of acute process?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph on ___
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The lungs
are clear without focal consolidation, pleural effusion or pneumothorax.
Specifically opacity within the right upper lobe has resolved compared to the
prior chest radiograph on ___.
IMPRESSION:
No acute cardiopulmonary process. Right upper lobe opacity has resolved.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Pain in right shoulder
temperature: 96.8
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | BRIEF SUMMARY
=============
Mr. ___ is a ___ year old male with PMH of tobacco use
(former) who presented to the hospital for tuberculosis rule out
after an indeterminate quantiferon gold test in the setting of
ground-glass opacities found incidentally on MRI of his
shoulder.
The patient underwent three induced sputums for AFB smear which
all returned negative. Our pulmonologists were consulted, and
several tests were ordered (TB PCR, hypersensitivity,
rheumatologic, cultures), many of which were pending at the time
of discharge. None were positive. On review of his imaging, they
felt that he likely had a multifocal pneumonia potentially from
a viral infection. Of note, the patient has significant PVC dust
exposure at his work, which has been associated with GGOs on CT
scan. The patient was discharged to follow up with his PCP and ___
pulmonologist after undergoing a repeat CT scan in 4 weeks from
discharge
ACUTE ISSUES
============
# Ground glass opacities: The patient was noted to have
ground-glass opacities incidentally found on an MRI or right
shoulder pain. A quantiferon gold test was performed, which was
indeterminate. He was admitted for tuberculosis rule out. On ROS
and exam, the patient did not have any significant symptoms nor
findings on exam other than shoulder pain. Pulmonology was
consulted, and several tests were ordered to evaluate for
autoimmune and infectious causes of these pulmonary
abnormalities. Many of these tests were pending at the time of
discharge and are listed in the transitional issues below. A
full set of negative labs can be seen in the lab section of this
document. The patient's acid fast smears came back negative x 3
and he was removed from precautions. Pulmonology reviewed his
OSH CT imaging, and felt his findings were likely a multifocal
pneumonia possibly from a virus. The patient also endorsed
significant inhalation of PVC dust at his job, and was advised
to wear a mask when around this dust. He was discharged to
follow up with pulmonology in ___ weeks as an outpatient, and
will need a CT scan in 4 weeks
# Anemia: Patient was noted to have an anemia, admission hgb
11.4, discharge 13.2 with no intervention. Iron studies
consistent with iron deficiency anemia. Unclear etiology.
# Tobacco Cessation? : Patient previously on wellbutrin for
tobacco cessation and continues.
- continued wellbutrin 50 mcg daily
# Right Arm Pain: Unclear etiology. Patient's arm pain appears
to have two components; a likely rotator cuff injury and a
potential nerve injury. He has a positive "empty can test" on
exam and his overhead lifting at work puts him at risk for
injury. His forearm and finger pain is excruciating and is in an
ulnar nerve distribution. He may have compression of the nerve
in the cubital tunnel or at the level of the brachial plexus.
His pain was controlled with APAP and tramadol.
TRANSITIONAL ISSUES
===================
-The patient will need repeat CT scanning in 4 weeks after
discharge. He will follow up with a pulmonologist in ___ weeks
from discharge
-The patient was noted to have a CRP of 17.8, which may be due
to a viral infection of the lung given his CT findings. The
etiology is unclear, however.
-Several tests were pending at the time of discharge, including
tuberculosis NAA test, ___, ANCA, sed rate, CCP ab, chlamydia
and gonorrhea nucleic acid probe test, as well as AFB cx and BCx
-Consider further evaluation of the patient's mild normocytic
anemia
-The patient was advised to wear a mask while working around PVC
dust |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Codeine / Demerol / Lisinopril
/ Bactrim DS
Attending: ___.
Chief Complaint:
cough, confusion, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of HTN, HLD, hypothyroidism, dementia who presents with
cough, weakness, confusion, admitted for pneumonia. Patient was
on a ___ cruise with her sisters for past 3 days
PTA however family noted she seemed weaker and not herself
therefore patient ended trip early and returned home today. At
that time, friends and family noted she was extremely weak with
cough and also confused. She has 24 hour nursing care at home
and
RNs noted low BP with tachycardia therefore EMS was called. Per
family friend at bedside, patient didn't know her husband, was
unaware of where she was. Patient is able to relay that cough
has
been present for several days and has gotten worse, sometimes
productive. She denies CP, SOB, f/c. No sick contacts but was
recently taking care of her grandchildren who are often sick.
She
denies dysuria, urinary urgency or frequency. Friend at bedside
states she is now closer to her normal baseline after receiving
abx. At baseline is forgetful but oriented.
In the ED, patient's vitals were as follows: T 102.8, HR 111, BP
129/73, RR 28, SpO2 96% on RA. CBC with leukocytosis to 15. CMP
with mild alk phos and T. Bili elevation. UA contaminated. She
had a CXR w/ RLL PNA. She was given IVF, CTX, azithro, and 1000
mg Tylenol. She was admitted to medicine for further work up and
management.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
HLD
Hypothyroidism
Dementia
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
On admission:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: resting in bed, appears fatigued
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: frequent coughing, breathing is non-labored, decreased
breath sounds at R base, no wheezing or crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to place, self, stated year was ___,
face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
On discharge: VSS, MS at ___, coughing improved, otherwise
unchanged from above
Pertinent Results:
___ 07:25AM BLOOD WBC-9.2 RBC-3.99 Hgb-11.5 Hct-31.1*
MCV-78* MCH-28.8 MCHC-37.0 RDW-12.9 RDWSD-37.1 Plt ___
___ 03:03PM BLOOD WBC-15.3* RBC-4.78 Hgb-13.9 Hct-38.8
MCV-81* MCH-29.1 MCHC-35.8 RDW-12.8 RDWSD-37.6 Plt ___
___ 07:25AM BLOOD Glucose-108* UreaN-7 Creat-0.5 Na-134*
K-3.5 Cl-97 HCO3-22 AnGap-15
___ 03:03PM BLOOD Glucose-138* UreaN-15 Creat-0.8 Na-135
K-3.8 Cl-93* HCO3-24 AnGap-18
___ 03:03PM BLOOD ___ PTT-28.2 ___
___ 07:25AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.6
___ 04:20AM BLOOD calTIBC-203* Ferritn-396* TRF-156*
___ 03:03PM BLOOD TSH-0.02*
___ 03:03PM BLOOD T4-13.2*
CXR:
Right lower lobe pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
2. Omeprazole 20 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO 6X/WEEK (___)
4. Aspirin 81 mg PO DAILY
5. Donepezil 10 mg PO QHS
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Day
RX *azithromycin 250 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*10 Capsule Refills:*0
3. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
4. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___)
RX *levothyroxine [Levo-T] 112 mcg 1 tablet(s) by mouth 6x/week
Disp #*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Donepezil 10 mg PO QHS
7. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with tachycardia, fever, AMS, cough// PNA?
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
Compared to prior, there is a new right infrahilar focal consolidation. There
is increased left basilar atelectasis. There is no pleural effusion or
pneumothorax. Heart size is normal.
IMPRESSION:
Right lower lobe pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Pneumonia, unspecified organism
temperature: 102.8
heartrate: 111.0
resprate: 28.0
o2sat: 96.0
sbp: 129.0
dbp: 73.0
level of pain: uta
level of acuity: 2.0 | Ms. ___ is a ___ female with PMH of HTN, HLD,
hypothyroidism, dementia who
presents with cough, weakness, confusion, admitted for
pneumonia.
#Community acquired PNA: she was treated with ceftriaxone and
azithro and improved, ultimately discharged on cefpodoxime and
azithro to complete a ___cute encephalopathy: delirium on dementia. Improved with
treatment of PNA and was at ___ at the time of discharge.
Aricept was continued on discharge
# tachycardia: sinus, resolved with fluids and treatment of
infx.
#Hypothyroidism - likely iatrogenic from too high synthroid
dose. Her home dose was decreased and she should follow up with
her PCP for repeat ___.
# Anemia: with low iron, no e/o bleeding. Mild and stable in
house. Pt will f/u with PCP for discussion of colonoscopy.
# elevated INR: mild, likely nutritional, pls monitor in the
outpt setting.
#HTN/HLD: continued home meds
#GERD: continued omeprazole
#Depression: continued Lexapro
# Hypophos: she was repleated in the hospital, please f/u as an
outpt
>30 min were spent on dc related activities |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old lady with history of type 2 DM, recent STEMI s/p DES
___ (c/b cardiogenic shock, systolic CHF), presenting with 5
days of epigastric discomfort and newly elevated liver enzymes.
History is notable for a recent STEMI (at ___ 3 weeks ago for
which she underwent cardiac stenting. She is anticoagulated on
ticagrelor. Her medical history is otherwise notable for
diabetes on metformin.
She reports that ___ she got her labs done and only had
elevated WBC (on my review, AST/ALT were normal at that time),
and then the next day started having abdominal discomfort
(epigastric, constant), "not pain just discomfort." No
associated nausea/vomiting, but malaise and lack of appetite.
Diarrhea ___ times. She reports her symptoms have been largely
unchanged for the past 5 days and she went to an urgent care
center earlier today where she was noted to have orange urine
which was positive for bilirubin. Today she feels slightly
better and is hungry.
In ED pt found to be hyponatremic, dehydrated with elevated
LFTs. RUQ US and CT abd/pel without obvious biliary pathology.
Trop neg x1, ECG at baseline. No medications or fluids given.
She took advil (3 pills BID) regularly for rheumatoid arthritis
before hospitalization but hasn't taken any since. Stopped
lisinopril last week. Other recent med changes were ticagrelor,
atorvastatin, and metoprolol from recent admission ___. No
other new med changes. Not sexually active, no IVDU, no alcohol.
ROS: denies any fever, chills, chest pain, shortness of breath,
pain with urination, bowel changes. She reports that she has had
decreased appetite for the past 5 days and has lost some weight
during this period. +as above, otherwise reviewed and negative
Past Medical History:
CAD s/p NSTEMI and PCI ___
DM2
Hyperlipidemia
Hypothyroidism
Rheumatoid arthritis
Osteoarthritis
Spinal stenosis
Colonic adenoma
Carpal tunnel syndrome
OSTEOARTHRITIS-THUMB CMC-R
History of tobacco use
Advanced directives, counseling/discussion
Overweight
Hypothyroidism
Radiculopathy, cervical
Colonic adenoma
Osteopenia
Hyperlipidemia LDL goal < 100
Palpitations
Diabetes type 2, controlled
Rheumatoid arthritis
PPD negative
Radiculopathy
Cervical myelopathy
orencia - High risk medications (not anticoagulants) long-term
use
Pain in limb
STEMI (ST elevation myocardial infarction)
Social History:
___
Family History:
Brother with MI s/p stent at age ___
Brother and sister with DM
No family history of gallstone/gallbladder problems.
Physical Exam:
Vitals: 98.3 - 125/70 - 100 - ___ - 98RA, ___ 151
PAIN: ___
General: nad, pleasant
EYES: sclera are anicteric, mucous membranes a bit dry
Lungs: clear bilaterally
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, minimally tender to
palpation, no rebound or guarding
Ext: no edema
Skin: no rash
Neuro: alert, follows commands, oriented x3, appropriate
Pertinent Results:
___ 01:25PM GLUCOSE-130* UREA N-15 CREAT-0.6 SODIUM-130*
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-21* ANION GAP-18
___ 01:36PM LACTATE-2.5*
___ 01:25PM ALT(SGPT)-190* AST(SGOT)-135* ALK PHOS-450*
TOT BILI-2.5* DIR BILI-1.7* INDIR BIL-0.8
___ 01:25PM LIPASE-46
___ 01:25PM cTropnT-<0.01
___ 01:25PM ALBUMIN-3.4*
___ 01:25PM WBC-10.7* RBC-3.80* HGB-11.3 HCT-33.2* MCV-87
MCH-29.7 MCHC-34.0 RDW-15.4 RDWSD-49.2*
___ 01:25PM NEUTS-71.9* LYMPHS-11.7* MONOS-9.8 EOS-5.7
BASOS-0.5 IM ___ AbsNeut-7.67* AbsLymp-1.25 AbsMono-1.04*
AbsEos-0.61* AbsBaso-0.05
___ 01:25PM PLT COUNT-223
___ 06:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:32PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 06:32PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
CT Abd/Pel IMPRESSION:
1. No intra- or extrahepatic biliary ductal dilatation. No
pancreatic mass is seen. No pancreatic ductal dilatation.
Nondistended gallbladder with slightly prominent, possibly
subtly hyperemic wall can be seen with minimal gallbladder wall
edema, although this was not substantiated on preceeding
ultrasound.
2. Top-normal diameter appendix containing high
density/appendicoliths,
without other findings to suggest acute appendicitis.
3. Calcified subserosal uterine fibroid.
4. Nonspecific lucent lesion in the medial right iliac bone of
indeterminate age ; no priors for comparison, however, the lack
of cortical
breakthrough/destruction suggest that it may be nonaggressive
___ 16:15 Liver Or Gallbladder Us (Single Organ) [64]
1. Mild hepatic steatosis.
2. Normal gallbladder and common bile duct without evidence of
acute
cholecystitis.
___ 05:10AM BLOOD WBC-8.7 RBC-3.53* Hgb-10.5* Hct-30.8*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.7* RDWSD-49.4* Plt ___
___ 05:10AM BLOOD Glucose-133* UreaN-10 Creat-0.6 Na-133
K-3.5 Cl-96 HCO3-22 AnGap-19
___ 05:10AM BLOOD ALT-143* AST-87* AlkPhos-509* TotBili-1.3
___ 05:10AM BLOOD ALT-167* AST-124* AlkPhos-459*
TotBili-1.5
___ 05:10AM BLOOD calTIBC-261 Ferritn-417* TRF-201
___ 11:00PM BLOOD Hapto-321*
___ 01:25PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:45AM BLOOD AMA-PND Smooth-PND
___ 08:45AM BLOOD ___
___ 08:45AM BLOOD ___
___ 05:10AM BLOOD IgG-1186 IgA-481*
___ 01:25PM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TiCAGRELOR 90 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcium Carbonate 650 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO Q24H
8. Multivitamins 1 TAB PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 650 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. TiCAGRELOR 90 mg PO BID
7. Vitamin D 400 UNIT PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
acute transaminitis/cholestasis
may be due choledocolithiasis (passed stone) vs drug induced
liver injury
CAD, recent STEMI
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 hyperbilirubinemia. Assess for CBD obstruction?
Cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is mildly echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 10.3 cm.
KIDNEYS: The right kidney measures 11.7 cm. The left kidney measures 11.9 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Mild hepatic steatosis.
2. Collapsed gallbladder without evidence of acute cholecystitis. Normal
caliber common bile duct.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with painless jaundice,
hyperbilirubinemiaNO_PO contrast // Please eval for CBD obstruction,
pancreatic lesion, other causes of hyperbilirubinemia
TECHNIQUE: Single phase split bolus contrast: 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.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
4) Spiral Acquisition 4.2 s, 45.5 cm; CTDIvol = 13.9 mGy (Body) DLP = 629.8
mGy-cm.
Total DLP (Body) = 643 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Minor basilar atelectasis is seen, including involving the
lingula. No focal consolidation is seen. There is no pleural or pericardial
effusion. The partially imaged heart may be mildly enlarged.
ABDOMEN:
HEPATOBILIARY: Millimetric hypodensities are seen scattered in the liver, for
example 4 mm hypodensity in the left lobe posteriorly on series 2, image 13
skull symphysis, too small to further characterize on this study, however
which may represent cysts or biliary hamartomas. The liver otherwise appears
diffusely mildly low in attenuation. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is not distended, but there
may be minimal wall edema.
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 collapsed. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is colonic
diverticulosis without evidence of acute diverticulitis. The appendix is
borderline in diameter, measuring up to 7 mm a contains some high density/
appendicolith, within, however, is thin-walled and without adjacent fat
stranding.
PELVIS: The urinary bladder is relatively collapsed, but grossly unremarkable.
The distal ureters are also grossly unremarkable. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: Subserosal calcified uterine fibroid is seen extending to
the deep left pelvis, measuring approximate 1.7 x 1.5 cm. Aside from this, no
adnexal mass is identified.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Atherosclerotic changes are
seen along the aorta and bilateral iliac arteries.
BONES: Multilevel degenerative changes are seen along the spine. There is
minimal anterolisthesis of L4 over L5. There also multiple levels of facet
arthropathy and disc vacuum phenomenon. There is 2.5 X 1.3 cm lucent lesion
in the medial right iliac bone on series 2, image 44, which is nonspecific.
No overlying cortical destruction is seen and this lesion is most likely
nonaggressive.
IMPRESSION:
1. No intra- or extrahepatic biliary ductal dilatation. No pancreatic mass is
seen. No pancreatic ductal dilatation. Nondistended gallbladder with
slightly prominent, possibly subtly hyperemic wall can be seen with minimal
gallbladder wall edema, although this was not substantiated on preceding
ultrasound.
2. Top-normal diameter appendix containing high density/appendicoliths,
without other findings to suggest acute appendicitis.
3. Calcified subserosal uterine fibroid.
4. Nonspecific lucent lesion in the medial right iliac bone of indeterminate
age ; no priors for comparison, however, the lack of cortical
breakthrough/destruction suggest that it may be nonaggressive.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Abd pain, Jaundice
Diagnosed with Unspecified jaundice, Nonspec elev of levels of transamns & lactic acid dehydrgnse
temperature: 96.0
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 73.0
level of pain: 2
level of acuity: 3.0 | ASSESSMENT AND PLAN:
___ year old lady with history of type 2 DM, recent STEMI s/p DES
___ (c/b cardiogenic shock, systolic CHF), presenting with 5
days of epigastric discomfort and newly elevated liver enzymes.
#Cholestasis/Transaminitis: Suspected to be from
choledocolithiasis no longer seen on CT scan and ultrasound that
may indicate a passed stone vs. drug induced liver injury from
statin vs. auto-immune liver disease/hepatitis.
Notably, when labs were checked in primary care setting Last
week on ___ ALT 24, AST 31 and this was while she had been
on high dose Lipitor for at least a week following discharge
from ___ after STEMI.
Radiology felt that missing a biliary stone was unlikely given
CT and ultrasound both not showing stones or ductal dilatation
and thus MRCP was not pursued as she had no clinical evidence of
cholangitis.
Hepatology consulted. They felt this could be lab pattern
consistent with passed choledocolithiasis vs. liver injury from
statin vs. auto-immune hepatitis. They will help arrange f/u in
___ clinic at ___. Dr. ___ the patient.
T bili improved although alk phos rose slightly before discharge
from 450 to 500 although transaminitis improved. THese values
were reviewed with hepatology. They said next step would be to
offer her MRCP but that she did not need to stay for it and that
if her LFTs did not normalize she should have MRCP and then
potentially a liver biopsy pending results of auto-immune
hepatitis serologies.
We will continue to hold atorvastatin until repeat labs show
improvement.
# CAD: Continue home metoprolol, ASA 81 mg, ticagrelor 90mg BID,
hold atorvastatin.
# Chronic systolic CHF: On previous admission, she was found to
have EF 40%
with moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the distal ___ of the
anteroseptum, anterior, and distal anterolateral wall and apex.
She was started on metoprolol but did not tolerate captopril
(became hypotensive to ___ with baseline BPs 120s). Last
discharge weight 66.9 kg. Check daily weights, continue meds.
CHRONIC ISSUES:
================
#DM2: Maintain on ISS while in house; Last A1c 6.8%. resume
metformin on discharge
#Hypothyroidism: Continue home levothyroxine 75mcg
#Hyperlipidemia: Hold statin
#Healthcare maintenance. Continue MVI, vitamin D, calcium
carbonate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Torsemide / ACE Inhibitors
Attending: ___.
Chief Complaint:
Fever and shaking chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o h/o HTN, DMII, CKD V on HD ___ presenting
with chills and fevers. Patient reports that he was at his usual
dialysis session when he developed shaking chills. He states
that his temperature there was 100.1. He denied any chest pain,
SOB, abd pain, HA, joint pain, n/v. He states that he completed
dialysis and was sent to the ED to be evaluated. The patient
makes urine despite being on HD. He has not noted any
swelling/pain at his HD line. He has a maturing fistula on his
left arm. He denies any shortness of breath.
Patient was recently admitted from ___ for shortness of
breath and uremia and was ultimately initiated on dialysis. HD
work-up was notable for positive Quantiferon Gold and he was
initiated on INH 2 weeks ago.
In the ED initial vitals were: 99.8 101 157/56 18 95%
Labs were notable for: white cell count of 23 with 87%
Neutrophils, lactate of 1.5, H/H of 8.4 and 26.7, bicarb of 34
and creatinine of 2.8.
- Patient was given IV vancomycin and ceftriaxone.
Vitals prior to transfer were: 98.7 77 165/55 19 100% Nasal
Cannula
On the floor, patient reports feeling very well. He was able to
complete his HD session and has felt well since HD ended. ROS
entirely negative at this point. Has been compliant with all his
medications
Past Medical History:
-CKD V - just initiated on HD ___
-PROTEINURIA
-HYPERCHOLESTEROLEMIA
-HYPERTENSION
-NEUROPATHY - DIABETIC
-T2DM Insulin Dependent
-Mild nonproliferative diabetic retinopathy
- Latent TB initiated on INH ___
Social History:
___
Family History:
No history of renal disease. Sister - hypertension.
Physical Exam:
EXAM ON ADMISSION:
Vitals - T:98.1 BP:150/65 HR:82 RR:18 02 sat: 952L
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased breathing sounds at the bases, crackles in lower
lung fields, mainly right lung field. Breathing comfortably with
mild use of accessory muscles
ABDOMEN: protruberant, nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis or
clubbing, 1+ firm edema in the ___. No paresthesias.
Amputation of both ___ and ___ toes in right foot. Skin grafts
on both shins.
PULSES: 2+ DP pulses bilaterally
NEURO: Awake and answering questions. CN II-XII intact. A&Ox3.
no asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
ACCESS: PIV, tunneled R chest HD line looks c/d/i with no
erythema
EXAM ON DISCHARGE:
Tc(Tm):98.8(99.7) BP:145-150/46-61 ___ RR:18 O2:98RA
Gen: awake, alert and oriented to person, place, and time, no
apparent distress
HEENT: sclerae anicteric, mucus membranes moist, no oral mucosal
erosions or ulcers
Cardiac: regular rate and rhythem, no murmurs, gallops, or rubs
Resp: breathing comfortably, decreased lung sounds at bases
bilaterally, no wheezes, rhonchi, or rales
Abd: soft, non-tender, moderately distended, normoactive bowel
sounds
GU: no suprapubic pain, no costo-vertebral tenderness
Skin: fistula site clean, dry, intact, with palpable thrill and
bruit; chest wall hemodialysis catheter site clean, dry, intact
with no fluctuance or purulent drainage
Extremities: warm and well perfused, right knee pain with active
and passive movement, decreased range of motion with flexion and
extension; no erythema around right knee or overlying skin
changes, but focal tenderness to palpation near right medial
tibial plateau; right knee slightly warmer than left knee;
moderate suprapatellar swelling and joint effusion medial to
patella
Pertinent Results:
LABS ON ADMISSION:
___ WBC-23.1*# Hgb-8.4* Hct-26.7* Plt 269
___ Glucose-200* UreaN-18 Creat-2.8*# Na-140 K-4.0 Cl-96
HCO3-34* AnGap-14
___ Calcium-9.4 Phos-1.5*# Mg-1.9
___ Lactate-1.5
.
LABS ON DISCHARGE:
___ WBC-11.5* Hgb-9.2* Hct-29.4* Plt ___
___ Glucose-132* UreaN-35* Creat-4.4* Na-135 K-4.3 Cl-91*
HCO3-29 AnGap-19
___ Calcium-10.0 Phos-3.4 Mg-2.2
UA ___: trace blood. neg nitrite. >600 protein. large leuks.
12 RBC, >182 WBC, few bacteria
.
MICRO:
URINE CULTURE (___):
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
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--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
BLOOD CULTURE x 2 (___): NGTD
.
STUDIES AND IMAGING:
CXR (___): Mild pulmonary vascular congestion, improved from
the previous exam, without focal consolidation to suggest
pneumonia.
Knee xray (___):
Joint effusion present. No evidence of crystal deposition or
bony abnormality except mild unchanged degenerative spurring.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin (Buffered) 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Calcitriol 0.5 mcg PO DAILY
9. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Isoniazid ___ mg PO 2X/WEEK (___)
11. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Aspirin (Buffered) 81 mg PO DAILY
2. Isoniazid ___ mg PO 2X/WEEK (___)
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Nephrocaps 1 CAP PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day for
constipation Disp #*60 Capsule Refills:*0
11. HydrALAzine 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth four times per day
Disp #*120 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
daily Refills:*0
13. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily for
constipation Disp #*30 Capsule Refills:*0
14. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
15. CefTAZidime 1 g IV POST HD (TH) Duration: 1 Dose
Administer dose on ___ after hemodialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Urinary tract infection
Secondary:
End stage renal disease on dialysis
Insulin dependent diabetes mellitus
Hypertension, poorly-controlled
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 fever, hypoxia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Right-sided dual lumen central venous catheter tip terminates in the right
proximal right atrium. Heart size is normal. Aortic knob is calcified.
Mediastinal and hilar contours are unremarkable. Mild pulmonary vascular
congestion is noted, improved compared to the previous exam. No focal
consolidation, pleural effusion or pneumothorax is demonstrated. Linear
opacities within the left upper lobe are unchanged, compatible with scarring.
No acute osseous abnormalities identified.
IMPRESSION:
Mild pulmonary vascular congestion, improved from the previous exam, without
focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old man with ESRD and UTI now with acute right knee
swelling, with warmth and tenderness with movement. // r/o fluid collection,
acute process
COMPARISON: RIGHT KNEE RADIOGRAPHS FROM ___
FINDINGS:
There is a large right knee joint effusion, seen on the cross-table lateral
view. This bulges of the distal quadriceps tendon anteriorly, suggesting
considerable distention of the joint. There are mild tricompartmental
degenerative spurring. No focal bone erosion or aggressive osteolysis is
detected. No periosteal new bone formation is seen. Slightly patchy bone
density in the proximal tibia is probably not significantly changed allowing
for technical differences and may relate to disuse or background ESRD. No
fracture or fat fluid level is identified. No chondrocalcinosis.
IMPRESSION:
1. Large joint effusion, larger than on ___. The presence or
absence of infection within the joint cannot be evaluated by imaging.
2. No bone erosion or other radiographic evidence of osteomyelitis.
3. Mild degenerative spurring is unchanged.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, DIABETES UNCOMPL JUVEN, END STAGE RENAL DISEASE
temperature: 99.8
heartrate: 101.0
resprate: 18.0
o2sat: 95.0
sbp: 157.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old male with history of hypertension,
diabetes, chronic kidney disease on HD ___ presenting with
chills and fevers at HD session found to have leukocytosis and
UA/urine culture revealing UTI. He will complete a 7-day course
of antibiotics.
Active Issues
# Sepsis from Urinary Source
Patient presented with fever and leukocytosis initially
concerning for bacteremia given history of dialysis, but was
found to have a positive urine culture revealing E. coli and
GNRs. No clear predisposing factor to UTI aside from decreased
urine production on dialysis. No evidence of infection
surrounding tunneled catheter site or signs of pneumonia on exam
or CXR. Given early concern for bacteremia was started on broad
spectrum antibiotic coverage with Vancomycin and Ceftazidime.
This was then narrowed to ceftriaxone following urine culture.
Patient subsequently afebrile and otherwise hemodynamically
stable. He was discharged on antibiotic regimen after 5 days of
ceftriaxone with plan for one dose of 1g ceftazidime on ___
after HD to complete the antibiotic course. E. coli on culture
was susceptible to ceftriaxone and ceftazidime. Will have
follow-up with PCP after discharge.
# Right Knee Effusion
On the day of discharge he had new onset right knee pain and
swelling. This has occurred similarly during his last admission
in ___ which resolved spontaneously. He remained afebrile and
ambulatory. No trauma. Knee film did not show fracture or
evidence of CPPD, but did show an effusion. This was felt to be
most likely inflammatory rather than infectious. This should be
monitored at follow-up and if not resolved, consider an
arthrocentesis for further evaluation.
# Hypertension
Admitted on losartan and metoprolol. His blood pressure was
elevated to SBP 150's-180's during this admission. We restarted
hydralazine and amlodipine that had been discontinued during
previous admission with which his SBP improved to 140s-150s.
Chronic Issues
# ESRD on HD ___
No evidence of line infection as above. Dialysis schedule was
continued while inpatient. His phosphate was low so sevelamer
was discontinued. Home nephrocaps and vitamin D were continued.
Calcitriol was discontinued at it had been recently discontinued
as an outpatient per renal.
# Latent Tuberculosis
Patient recently started on INH therapy for latent TB for 9
month course. INH and pyridoxine were continued.
# Insulin Dependent Diabetes
Home glargine was continued with sliding scale coverage with
humalog.
# Hyperlipidemia
Continued home statin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
___: MEDICINE
Allergies:
metformin
Attending: ___.
Chief Complaint:
atypical chest pain
Major Surgical or Invasive Procedure:
atypical chest pain - no intervention, increased Metoprolol dose
pseudothrombocytopenia - platelet clumping, seen by Hematology,
no evidence of HIT, platelets normalized to 184 on ___. Given
documented history of sickle cell from last ___ admission's
review of records by the ___ medical team, ensure follow up and
referral from PCP for ongoing management for this issue
History of Present Illness:
Mr. ___ is a very pleasant ___ year old man with known
CAD (s/p CABG in ___, ___, known ___
cardiomyopathy (EF ___ s/p ICD (presumably placed for
primary prevention though he had an episode of VF recorded
subsequently), hx of LV thrombus (no longer on Coumadin given
compliance issues/supratx INRs), HTN, HLD, diabetes, chronic
pain and schizoaffective disorder who presented to the ED with
chest pain.
He reports having chest pain since his CABG in ___ that lasts
about 20 minutes and occurs at rest. He is able to get dressed,
take a shower, go out for a ___ Mi walk to get food (only eats
outside) without any chest pain. He has had several admissions
to our ED with similar symptoms last one in ___. He was
recently started on Imdur, but did not take the medication
despite having a ___ that sees him daily. He thinks his weight
is stable though he doesn't weight himself. His ___ checks his
BP and apparently has been on target. He had more severe chest
pain and thus came to our ED.
In the ED initial VS were Pain ___, T 97.7 F, HR 80, BP 96/62
mmHg, RR 16, SpO2 99%RA. ECG showed: borderline AV conduction
delay, ___ ST TW changes, flattened TW suggestive
of hypokalemia. One ECG showed ST segment changes and TW
compatible with systolic overload. Labs were significant for
Trop <0.01 x2, WBC 5.1, HGB 11.8, PLT186, Cr 1.9 (baseline 1.4),
glucose 156, Na 134, K 4.3, Co2 23, BNP 375, normal LFTs, Mg
1.9, Ca 9.1. He underwent pMIBI that showed a New moderate small
partially reversible defect of the inferior
myocardial wall and he is now admitted for further management.
Received ASA, 1L NS, Atorvastatin 80 mg, Benztropine Mesylate 1
mg, Colace, Haldol 5 mg, OxyCODONE--Acetaminophen (___) 1
TAB, Seroquel, Lisinopril 2.5, Metoprolol Succinate XL 25 mg,
Pantoprazole 40 mg, sertraline,
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.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- CAD s/p MI in ___ and CABG for ___ in ___
- CHF with LVEF of ___ in per ___ TTE now s/p ICD
- Delusional and affective thought disorder
- Hypertension
- Hyperlipidemia
- Type 2 diabetes, not currently on medications
- History of LV thrombus. Failed Coumadin per ___ notes in ___
due to noncompliance and supratherapeutic INR's
- History of DVT and PE in ___, previously on Coumadin
- Chronic chest pain due to sternotomy
- Chronic back pain
- MVC (struck pedestrian) in ___
- Possible PTSD due to MVC
- Diverticulosis
- History of thyroid nodule
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission ___:
VITAL SIGNS - Temp 98.1 F, BP 132/62 mmHg, HR 68 BPM, RR 16 X',
___ 100% RA
GENERAL - ___ man in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
___ 06:15AM BLOOD ___
___ Plt ___
___ 06:50AM BLOOD ___
___ Plt ___
___ 06:50AM BLOOD ___
___ Im ___
___
___ 11:28AM BLOOD Plt ___ Plt ___
___ 11:28AM BLOOD ___ ___
___ 06:20AM BLOOD ___ Plt ___ TO
___ 11:26AM BLOOD ___ Plt ___
___ 11:28AM BLOOD ___ ___
___ 02:16PM BLOOD ___
___ Plt ___ TO
___ 12:30PM BLOOD ___
___ Plt ___
___ 12:30PM BLOOD ___
___ Im ___
___
___ 06:20AM BLOOD Plt ___ TO Plt ___ TO
___ 02:16PM BLOOD Plt ___ TO Plt ___ TO
___ 06:35AM BLOOD Plt ___ Plt ___
___ 12:30PM BLOOD Plt ___
___ 12:30PM BLOOD ___ ___
___ 06:20AM BLOOD ___
___ 06:35AM BLOOD ___
___
___ 12:30PM BLOOD ___
___
___ 12:30PM BLOOD ___
___ 02:16PM BLOOD cTropnT-<0.01
___ 10:49AM BLOOD ___ cTropnT-<0.01
___ 06:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD ___
___ 06:20AM BLOOD ___
___ 06:35AM BLOOD ___
___ 12:30PM BLOOD ___
___ 06:35AM BLOOD ___
___ 11:28AM BLOOD ___
___ ___ STRESS IMPRESSION:
1. New moderate small partially reversible defect of the
inferior myocardial wall.
2. Moderate fixed defects of the anterior wall, septum, and
apex not significantly changed from prior study.
3. Global hypokinesis.
The calculated left ventricular ejection fraction is 27%, with
an ___ volume of 172 ml. This is improved over the
prior study which showed an ejection fraction of 17% and an end
diastolic volume of 192 ml.
IMPRESSION:
1. New moderate small partially reversible defect of the
inferior myocardial wall.
2. Moderate fixed defects of the anterior wall, septum, and
apex not significantly changed from prior study.
3. Global hypokinesis.
___ PORTABLE CHEST:
In comparison with the study ___, there is little overall
change. Low lung volumes accentuate the prominence of the
transverse diameter of the heart in this patient with previous
CABG procedure and intact midline sternal wires. Mild
indistinctness of pulmonary vessels could reflect some elevated
pulmonary venous pressure. Bibasilar atelectatic changes are
again seen with no evidence of pneumothorax.
KUB ___:
There are no abnormally dilated loops of large or small bowel.
Air is seen throughout the large and small bowel. There is no
free intraperitoneal air. Osseous structures are unremarkable.
There are cholecystectomy clips in the right upper quadrant. A
pacemaker and median sternotomy wires are partially visualized.
There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION:
Nonobstructive ___ pattern. No free intraperitoneal air.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Benztropine Mesylate 1 mg PO BID
3. Lidocaine 5% Ointment 1 Appl TP TID:PRN lower extremity pain
4. QUEtiapine Fumarate 50 mg PO QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Haloperidol 0.5 mg PO TID:PRN crossing the street
7. Haloperidol 5 mg PO BID
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Psyllium Powder 1 PKT PO DAILY
10. Senna 8.6 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Call ___ if
maximum of 3 tablets needed
14. OxyCODONE--Acetaminophen (___) 1 TAB PO Q8H:PRN back
or leg pain
15. Pantoprazole 40 mg PO Q24H
16. Aspirin 81 mg PO DAILY
17. Sertraline 200 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Benztropine Mesylate 1 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Haloperidol 5 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Call ___ if
maximum of 3 tablets needed
8. OxyCODONE--Acetaminophen (___) 1 TAB PO Q8H:PRN back or
leg pain
9. Pantoprazole 40 mg PO Q24H
10. Psyllium Powder 1 PKT PO DAILY
11. QUEtiapine Fumarate 50 mg PO QHS
12. Senna 8.6 mg PO BID
13. Sertraline 200 mg PO DAILY
14. Haloperidol 0.5 mg PO TID:PRN crossing the street
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Disposition:
Home With ___
Facility:
___
Discharge Diagnosis:
atypical chest pain - continued medical therapy - increased
Isosorbide to 60 mg Daily, your Metoprolol was also increased to
50 mg Daily
Pseudothrombocytopenia - likely result of Heparin SC for DVT
prophylaxis, currently stable at 184. Seen by Hematology.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: T 98.2 HR ___ RR 18 BP ___ 100% RA
Tele: Discontinued
Physical Exam:
Subjective: denies pain, NAD.
NECK - supple, no JVD appreciated, mucus membranes dry
LUNGS - CTA bilaterally
HEART - RRR no M/R/G
ABDOMEN - slightly distended, firm, compressible, ___,
+BS
EXTREMITIES - Distal pulses intact, CSM wnl, no pedal edema
SKIN - Warm/dry/intact
NEURO/psych - Alert, oriented and answering all questions
appropriately pleasant but flat affect
Assessment/Plan: ___ year old man with known CAD (s/p CABG in
___, ___, ICMP (EF ___ and s/p ICD, (hx of LV
thrombus (no longer on Coumadin given compliance issues/supratx
INRs), HTN, HLD, diabetes, chronic pain and several psychiatric
diagnosis, who presented to the ED with chest pain. EKG w/o
changes and troponins negative. Decision made for medical
management.
# Chest Pain Longstanding history for presumed angina symptoms
even after prior PCIs. He was recently admitted ___ to ___
___ with a presentation for nausea, emesis, constipation and
chest pain. This was felt to not be cardiac in nature and ECG
and troponins were negative, as has been found this admission as
well.
- Continue Metoprolol succinate 50mg daily
- Cont ASA and atorva 80mg
- Continue Imdur 30 mg
- Follow up with Dr. ___
- Encourage PO hydration - patient continues to be poorly
motivated to be OOB and interactive with his environment.
Ambulating unit currently with encouragement
# Chronic systolic heart failure - LVEF 35%. - clinically stable
- ischemic CMP
- Euvolemic now, no PND, leg swelling, etc.
- ___ diet, daily weights
- continue ASA/ACEI/Imdur
# ICD - clinically stable
- for primary prevention
# CKD - stage III Cr 1.6, GFR 44
- Avoid nephrotoxic agents and ensure appropriate hydration,
# HTN - clinically stable
- continue increased metoprolol succinate 50mg daily
# Hyperlipidemia - clinically stable
- Continue atorvastatin 80 daily
# DM2 - clinically stable
- Diabetic diet
# Heme - clinically stable
- Platelet clumping on last CBCs: hematology consulted,
identified as artifact, risk for HIT is very low
- Plt count currently stable
- Hx DVT/PE ___ - ___ with Coumadin
- He has a record of a positive blood test for sickle cell and
requires further outpatient workup.
# Abdominal pain - resolved, stable
- KUB reveals no obstruction but significant stool and some
dilated loops of bowel. Pt. reports multiple BMs since admission
# Psych
- Delusional disorder
- Continue home Haldol, Zoloft and sertaline
- Follow up with ___
# Chronic Pain - stable
- Has chronic pain agreement with PCP
- ___ at home and has been taking at least daily
while here for chronic back pain
# FEN - regular low salt cardiac healthy diet. labs stable
Dispo: The current guardian indicates he wants to relinquish
responsibility but current guardian remains for now Mr. ___
___ . He has now been approved for
___ Insurance which is accepted by
___.
discharge to home with ___
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with L anterior chest pain, hypotension // Eval for
acute process Eval for acute process
IMPRESSION:
In comparison with the study ___, there is little overall change. Low
lung volumes accentuate the prominence of the transverse diameter of the heart
in this patient with previous CABG procedure and intact midline sternal wires.
Mild indistinctness of pulmonary vessels could reflect some elevated pulmonary
venous pressure. Bibasilar atelectatic changes are again seen with no
evidence of pneumothorax.
Radiology Report
INDICATION: ___ year old man with CAD, HTN, DM presents with chest pain who
now is complaining about left lower quadrant pain // rule out acute process
like obstructions, perforations
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Air is seen
throughout the large and small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are cholecystectomy clips in the right upper quadrant. A pacemaker and
median sternotomy wires are partially visualized. There are no unexplained
soft tissue calcifications or radiopaque foreign bodies.
IMPRESSION:
Nonobstructive bowel-gas pattern. No free intraperitoneal air.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs, Essential (primary) hypertension
temperature: nan
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 96.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | The patient had an unremarkable hospital course. He
inconsistently reported chest pain to the physicians, but when
seen by the NP ___ on a daily basis denied any chest pain,
palpitations, shortness of breath. He was ambulatory in the
unit and encouraged to be up and out of bed more often. He was
pleasant and cooperative. His current guardian was ultimately
contacted after much difficulty and consented to the
catheterization procedure on ___ with a plan to proceed to the
catheterization lab on ___. His guardian expressed a
desire to be replaced and ___ Case Management, Social Work and
Legal were heavily involved in these issues and is working
towards assignment of a new guardian at the time of this
discharge summary. However for the time being guardian remains
unchanged. His insurance was changed to ___
___ so that his care can be continued with Dr. ___
___.
___, his vital signs remained stable, and he complained
of chest pain, pointing to his abdomen early in his course. A
KUB was ordered which revealed no pathology but with mild
dilated loops of bowel and significant stool throughout the
colon. He was maintained on a laxative regime and has reported
two bowel movements this stay. His abdomen remains distended
but ___ and he has as noted been counseled to be out of
bed and ambulating the unit to enhance bowel motility to prevent
ileus and other GI complications. He was maintained on his
chronic pain medication (Percocet) while hospitalized for his
low back pain. His telemetry remained stable with minimal
ectopy and occasional pauses. His creatinine has been noted to
be increased ranging from 1.6 to 1.9 from 1.3 in early ___.
He had been recently hospitalized at ___ in mid ___ and
managed by the ___ team and his creatinine averaged ___
during that time. His medications were carefully reviewed but
no further adjustments were made. During this hospitalization,
he was maintained initially on SC Heparin TID for DVT
prophylaxis given his history of DVT/PE in ___ ___
with Coumadin therapy and supratherapeutic INRs) and converted
to once daily Lovenox on ___. Of note, while hospitalized at
___ in mid ___ review of old records indicated he had had
prior blood tests with positive result for sickle cell for which
he has not sought care and further workup. This should be done
post discharge with his PCP. He has remained afebrile and his
white count remains normal, however his platelets have continued
to clump and as mentioned previously, he requires outpatient
workup for his sickle cell, and preferably a peripheral smear.
Differential was ordered while here and results are included in
this discharge summary. He was seen by Hematology who felt that
his drop in platelets to 105 and 110 respectively on ___ and ___
were likely pseudothrombocytopenia. His platelet count was
obtained using a yellow top tube and has since improved to 184
on ___. Of note, he was started on Lovenox on ___.
With regards to his catheterization, this was ultimately
cancelled after discussion with two interventionalists who felt
that his atypical chest pain was best managed medically. Should
he develop positive signs for NSTEMI or STEMI, then an
intervention would be performed. His Toprol was increased to 50
mg Daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tetracycline Analogues / Ciprofloxacin / Morphine / adhesive
tape / Morphine / Arthralgias
Attending: ___.
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with past medical history
including vertigo, migraines and prior smoking history who
presents to ___ ED ___ with worsening unsteadiness for 4
days. On ___, she gradually began to feel unsteady and
nauseous during the day. This felt like her typical vertiginous
symptoms so she called her PCP who prescribed her meclizine,
which typically helps with her vertigo. Unfortunately, the
meclizine provided her with no relief. Symptoms continued to
worsen and, on day of presentation, she also experienced two
episodes of chest pain. The pain was pressure-like, located in
the ___ her chest, and non-radiating. The pain occurred
twice throughout day of presentation and lasted 1 minute each
time. Pt again called her PCP who referred her to the ED.
At time of assessment, pt reported ongoing sensation of
unsteadiness. She states that her symptoms still feel like her
typical vertigo but she is concerned because her symptoms
typically do not last this long and typically resolve with
meclizine. The symptoms are worse with laying down, learning
forward, standing up, or moving her head in any direction. She
feels like she is "on an amusement park ride" whenever she lays
down. She denies a sensation of the room spinning around her.
She has also developed a dull left temporal dull headache over
the past hour which feels like the start of her typical
migraine. Quality of pain is squeezing. She has ongoing nausea
but has not
vomited. Chest pain had resolved at time of assessment. She
feels like she has been "stumbling" but denies any falls.
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies palpitations,
dyspnea, or cough. Denies vomiting, diarrhea, constipation, or
abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
DCIS S/P LUMPECTOMY (___)
CARPAL TUNNEL SYNDROME
GASTROESOPHAGEAL REFLUX
ROTATOR CUFF TENDONITIS
OBESITY
MIGRAINE HEADACHES
IRRITABLE BOWEL SYNDROME
ASTHMA
H/O PARTIAL HYSTERECTOMY
Social History:
___
Family History:
FAMILY HISTORY:
Mother: ___ cancer, migraines
Brother: Liver cancer
Father: ___ cancer
Sister: ___
No family history of stroke.
Physical Exam:
Vitals: T: 97.7 HR: 84 BP: 150/95 RR: 16 SaO2: 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, no carotid
bruit
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Speech
is
fluent 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. No apraxia. No evidence of hemineglect. No
left-right
agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus while pt is upright. Upon lying down, pt
describes nausea and unsteadiness and right-beating nystagmus is
elicited in primary gaze. ___ beats of nystagmus are also
elicited on upgaze when laying down that extinguish. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally or heel to shin bilaterally. Good speed and intact
cadence with rapid alternating movements.
- Gait - Normal initiation. Mild limp ___ right knee
osteoarthritis per pt. Narrow base. Positive Romberg.
**************
Repeat Exam on the floor:
No nystagmus in primary gaze. No cerebellar signs. Gait with
mild limp as noted above but narrow based and steady.
___ hallpike bilaterally with right torsional nystagmus but
worse with left ear down, with delayed onset of symptoms and
reproduction of symptoms with the maneuver.
Motor exam unremarkable.
Pertinent Results:
Admission Labs:
___ 12:14AM BLOOD WBC-7.6 RBC-4.81 Hgb-13.1 Hct-41.3 MCV-86
MCH-27.2 MCHC-31.7 RDW-14.3 Plt ___
___ 09:45AM BLOOD ___ PTT-35.2 ___
___ 12:14AM BLOOD Glucose-127* UreaN-16 Creat-1.0 Na-138
K-7.1* (hemolyzed) Cl-103 HCO3-24 AnGap-18
___:14AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.3
Cardiac enzyme:
___ 12:14AM BLOOD cTropnT-<0.01
___ 09:45AM BLOOD cTropnT-<0.01
___ 01:20PM BLOOD cTropnT-<0.01
Stroke Labs:
___ 09:45AM BLOOD Cholest-297* Triglyc-71 HDL-103
CHOL/HD-2.9 LDLcalc-180*
___ 02:55AM BLOOD %HbA1c-PND
___ 12:14AM BLOOD TSH-2.4
Stox: negative
Utox: negative
UA: positive for large ___ and bacteria but pt asymptomatic. UCx
with mixed flora, thought to be contamination.
Imaging:
CT head: No evidence of acute intracranial hemorrhage or obvious
large vascular territory infarction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough/wheeze
2. butalbital-acetaminophen-caff 50-325-40 mg oral daily
headache
3. carisoprodol 250 mg oral BID muscle tightness
4. DiCYCLOmine ___ mg PO Frequency is Unknown abdominal pain
5. letrozole 2.5 mg oral daily
6. Meclizine 25 mg PO Q8H:PRN vertigo
7. Mupirocin Ointment 2% 1 Appl TP BID
8. Nortriptyline 75 mg PO QHS
9. Omeprazole 40 mg PO DAILY
10. Sumatriptan Succinate 50 mg PO ONCE MR1 for migraines
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
12. Ibuprofen 400 mg PO Q6H:PRN pain
13. Daily Multiple For Women (multivit-iron-FA-calcium-mins) 18
mg iron-400 mcg-500 mg Ca oral daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough/wheeze
2. butalbital-acetaminophen-caff 50-325-40 mg oral daily
headache
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
4. carisoprodol 250 mg oral BID muscle tightness
5. Daily Multiple For Women (multivit-iron-FA-calcium-mins) 18
mg iron-400 mcg-500 mg Ca oral daily
6. DiCYCLOmine ___ mg PO BID:PRN abdominal pain
7. Ibuprofen 400 mg PO Q6H:PRN pain
8. letrozole 2.5 mg oral daily
9. Mupirocin Ointment 2% 1 Appl TP BID
10. Nortriptyline 75 mg PO QHS
11. Omeprazole 40 mg PO DAILY
12. Sumatriptan Succinate 50 mg PO ONCE MR1 for migraines
Do not take more than twice a week.
13. Diazepam 2 mg PO Q8H:PRN vertigo
DO NOT drive while taking this medication as it can make you
sleepy.
RX *diazepam 2 mg 1 tablet by mouth every 8 hours Disp #*10
Tablet Refills:*0
14. Outpatient Physical Therapy
Vestibular physical therapy for likely BPPV.
ICD-9: 386.11
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: benign paroxysmal positional vertigo,
migraines
Secondary Diagnosis: asthma
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: History: ___ with 5 days of vertigo // Evaluate for posterior
fossa lesions
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 55.75 mGy
DLP: 891.93 mGy-cm
COMPARISON: ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect, or
large territorial infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
The visualized bony structures are grossly unremarkable. The paranasal
sinuses and middle ear cavities are clear. Mastoids are partly not
pneumatized. The globes are unremarkable.
IMPRESSION:
No evidence of acute intracranial hemorrhage or obvious large vascular
territory infarction.
Correlate clinically to decide on the need for further workup with MRI if not
contraindicated of followup, if there is continued clinical concern.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with likely central vertigo // eval for
cardiopulmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___.
FINDINGS:
Low lung volumes results in crowding of the bronchovascular structures. A
previously identified right upper lobe pulmonary nodule is no longer visible
on today's study. Mild bibasilar atelectasis is noted. There is no evidence of
focal consolidation, pleural effusion, pneumothorax, or pulmonary edema. The
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dizziness, Headache
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.7
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 150.0
dbp: 95.0
level of pain: 1
level of acuity: 2.0 | Ms. ___ was admitted to neurology service given the
reported examination in the ED. However, repeat examination on
the floor was consistent with dysfunction in left vestibular
system. She was seen by ___ and was cleared for home with
Vestibular ___. As she reported no symptom improvement on
meclizine, valium was tried in the hospital with some
improvement in her symptoms, so she was discharged home with
order for outpt vestibular ___ and valium. She was instructed to
minimize the use of valium and to not drive while taking the
medication.
Her other stroke risk factor work up showed hyperlipidemia, but
no statin was started as her presentation was not consistent
with stroke and she had no other cardiac risk factors such as
diabetes. She should follow up with her PCP for the high LDL.
She was instructed to follow up with neurology as outpatient
which had been scheduled prior to this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sevoflurane / Orange Juice / Reglan / Bactrim
Attending: ___.
Chief Complaint:
Fevers, chills, nausea, vomiting, inability to take PO
Major Surgical or Invasive Procedure:
Graft Excision - ___
Tunnelled HD Catheter Placement - ___
History of Present Illness:
This is a ___ yo M with DM1 c/b nephropathy, ESRD on HD through
AV graft (TTS) and esophagitis who presents with three days of
fevers, chills, nausea, vomiting, and inability to tolerate PO.
The patient was ___ his USOH until ___ when he developed
intractable nausea after HD. The patient notes a normal HD
session only complicated by a small amount of bleeding at the
graft site. After HD, the patient had nausea and vomited some
food, bilious material, and what he says is "coffee ground"
color material. The patient did not have any hematemesis. He
vomited ___ times and was unable to eat or drink. The patient
denied any other GI symptoms including diarrhea, melena, or
hematochezia. He endorsed constipation, with no stool x 3 days.
With the vomiting, he had mild RLQ tenderness. He says that this
occurred intermittently on ___ and ___, but has resolved
completely. Along with these symptoms, the patient noted fevers
and shaking chills. He had slight, nonproductive cough without
SOB, wheezing, or chest pain. He noted more nocturnal cough and
reflux symptoms with supine positioning. He denied sore throat,
rhinorrhea, sick contacts, recent travel, no IV drug use, or
other exposures. He has diabetic neuropathy, but denies any
non-healing ulcers. Of note, he did cut his R foot over the
weekend, but did not notice any accompanying skin changes,
redness, or drainage.
___ ED, developed fever to 102.9. Patient was given vancomycin.
Guiac negative. CXR normal. CT abdomen performed without acute
process identified. The patient was sent to the HD unit prior to
coming to the floor for workup of fever.
Past Medical History:
- Diabetes mellitus, type I, c/b retinopathy (legally blind
on left), neuropathy and nephropathy, gastroparesis
- CAD, NSTEMI ___
- CHF
- Hypertension
- Pulmonary hypertension
- Glaucoma
- s/p surgical debridement of left arm fistula (___) and
ruptured aneurysm repair (___)
- History of PEA arrest ___ AV fistula repair
- History of positive PPD, s/p one year of treatment
- Hiccups.
- hx seizure d/o
Social History:
___
Family History:
Multiple siblings with hypertension and diabetes. Two sisters
with a "heart problem." No known early coronary disease or
kidney disease.
Physical Exam:
Admission Physical Exam:
VS - Temp 102.7 F, BP 158/67, HR 78, R 20, O2-sat 100% RA
GENERAL - tired appearing gentleman, AOx3
HEENT - anicteric sclera, mild conjunctival injection, legal
blindness of L eye, no tonsilar exudates
NECK - supple, no thyromegaly, no JVD, no LAD
LUNGS - limited by poor effort, no wheezes, crackles,
consolidations. equal breath sounds bilaterally
HEART - RRR, systolic machine like murmur at RUSB, no radiation
to carotids, likely referred from AV graft, no rubs, no extra
heart sounds
ABDOMEN - hypoactive bowel sounds, soft, NT, ND, no rebound,
guarding
EXTREMITIES - warm, ___ pulses bilaterally, small 2cm
laceration on R metatarsal callous, no skin changes
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, nonfocal
Medicine To Cardiology transfer:
VS: Tm 101 Tc 98.4 125/60 HR ___ on RA
Gen: well appearing
Heart: triphasic friction rub
Ext: right UE bandaged, incision with packing, no purulent
drainage
Discharge Exam:
Pertinent Results:
Admission Labs:
___ 09:30AM BLOOD WBC-10.5# RBC-4.45* Hgb-13.4*# Hct-40.3
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.8 Plt Ct-71*
___ 09:30AM BLOOD Neuts-89.4* Lymphs-6.1* Monos-3.9 Eos-0.3
Baso-0.3
___ 09:30AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL Burr-OCCASIONAL
___ 09:30AM BLOOD ___ PTT-35.2 ___
___ 09:22PM BLOOD ___ 10:40PM BLOOD ___ 09:30AM BLOOD Glucose-123* UreaN-89* Creat-13.4*#
Na-135 K-6.4* Cl-92* HCO3-19* AnGap-30*
___ 09:30AM BLOOD ALT-33 AST-55* LD(LDH)-789* CK(CPK)-260
AlkPhos-97 TotBili-0.4
___ 09:30AM BLOOD cTropnT-0.15*
___ 10:40PM BLOOD Albumin-4.3 Calcium-8.6 Phos-5.4* Mg-2.0
Medicine to Cardiology Transfer Labs:
___ 06:15AM BLOOD WBC-8.0 RBC-3.90* Hgb-11.4* Hct-36.0*
MCV-92 MCH-29.3 MCHC-31.8 RDW-14.7 Plt ___
___ 06:15AM BLOOD Glucose-152* UreaN-31* Creat-8.6*# Na-135
K-4.1 Cl-96 HCO3-27 AnGap-16
___ 06:15AM BLOOD ALT-2 AST-15 LD(LDH)-260* CK(CPK)-52
AlkPhos-92 TotBili-0.3
___ 06:15AM BLOOD Calcium-9.5 Phos-5.5* Mg-2.3
Cardiac Enzymes:
___ 09:30AM BLOOD cTropnT-0.15*
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.09*
___ 07:25AM BLOOD CK-MB-2 cTropnT-0.12*
___ 06:15AM BLOOD CK-MB-1 cTropnT-0.12*
MICRO:
___ 9:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___. ___ PAGER#
___ @ ___ ON
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 12:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___. ___ PAGER #
___ @ 0255
ON ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
___ 8:37 pm FOREIGN BODY Site: ARM
RIGHT UPPER ARM AV GRAFT.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___
___ 7:48 pm SWAB RIGHT AV GRAFT ABSCESS.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 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.
___ 2:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging:
CT Abdomen/Pelvis:
1. No evidence of intra-abdominal process to explain fevers.
2. 1.1-cm perifissural nodule ___ the right lower lobe. This is
not clearly identified on prior studies. Most likely, this is
simply a subpleural lymph node; however, given its size,
followup scan ___ three months would be recommended.
3. Atrophic kidneys ___ keeping with the patient's history of
end-stage renal disease.
Ultrasound RUE: ___
IMPRESSION:
1. Three hematomas surrounding the graft, possibly related to
graft access. No evidence of abscess.
2. Small, eccentric intraluminal vegetation or thrombus within
the superior-to-mid portion of the graft.
Ultrasound RUE: ___
___ comparison to ___ exam, two heterogeneous collections ___
the right arm, likely hematomas, have resolved. A single
heterogeneous collection adjacent to the graft persists, likely
a chronic hematoma, unchanged since prior.
Echo: ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion. Compared with the findings of the prior
study (images reviewed) of ___, the left ventricular
ejection fraction is reduced.
IMPRESSION: no vegetations seen
Trans-esophageal echo ___:
GENERAL COMMENTS:
Conclusions
No spontaneous echo contrast or thrombus is seen ___ 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. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal ___ diameter and free of
atherosclerotic plaque to 40 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified. No
vegetation/mass is seen on the pulmonic valve. There is a small
to moderate sized circumferential, pericardial effusion with
preferential fluid deposition adjacent to the left ventricular
free wall and inferior walls (maximal dimension of 1.2 cm (clip
69)). There are no echocardiographic signs of tamponade.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Small to moderate pericardial effusion without echocardiographic
evidence of tamponade. Normal biventricular systolic function.
Echo ___
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Sustained RA diastolic collapse, c/w low
filling pressures or early tamponade. RV diastolic collapse, c/w
impaired fillling/tamponade physiology. Significant, accentuated
respiratory variation ___ mitral/tricuspid valve inflows, c/w
impaired ventricular filling.
Conclusions
The right ventricular free wall is hypertrophied. The ejection
fraction is low-normal. There is a large pericardial effusion.
There is sustained right atrial collapse, consistent with low
filling pressures or early tamponade. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology, seen best ___ clip 10. There is significant,
accentuated respiratory variation ___ mitral/tricuspid valve
inflows, consistent with impaired ventricular filling.
Study terminated secondary to patient instability/cardiac
arrest.
IMPRESSION: Suboptimal image quality. Large pericardial
effusion. Sustained right atrial and right ventricular diastolic
collapse consistent with tamponade physiology. At least moderate
pulmonary hypertension.
Compared to the prior study (images reviewed) of ___, there
are signs of pericardial tamponade physiology and the
pericardial effusion has increased ___ size.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on left arm
___
ISOSORBIDE MONONITRATE - 60 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Daily
LOSARTAN [COZAAR] - 100 mg Tablet - one Tablet(s) by mouth once
a
day
DOXEPIN - 10 mg/mL Concentrate - 2.5 ml by mouth at bedtime as
needed for insomnia do not drive or use heavy machinery while
taking this medication. may repeat once prn
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 3units lantus ___ the morning
INSULIN SYRINGE-NEEDLE U-100 - 28 gauge X ___ Syringe - as
directed bid and prn
LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth every 12 hours
ONDANSETRON HCL - 4 mg Tablet - 1 (One) Tablet(s) by mouth three
times a day as needed for nausea
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 to 2 Tablet(s)
by mouth every six (6) hours as needed for pain
SEVELAMER HCL - 800 mg Tablet - one Tablet(s) by mouth three
times daily with meals
VIT B CPLX ___ [DIALYVITE] - 1 mg Tablet - one
Tablet(s) by mouth daily
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC with Differential and Chem 10 panel every
___ at Hemodialysis. Please fax results to ___ clinic at
___.
ICD9 790.7
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every ___.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
12. doxepin 10 mg/mL Concentrate Sig: 2.5 mL PO at bedtime.
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
14. loperamide 2 mg Capsule Sig: One (1) Capsule PO every ___
hours as needed for diarrhea.
15. Lantus 100 unit/mL Solution Sig: Three (3) units
Subcutaneous at bedtime.
16. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day as needed for hyperglycemia:
Follow sliding scale.
17. cefazolin 1 gram Recon Soln Sig: ___ grams Intravenous once
a day for 6 weeks: Please give 2 grams after hemodialysis on
___. Give 3 grams after HD on ___. End on ___ .
18. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
19. diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for anxiety or leg pain.
20. heparin (porcine) 1,000 unit/mL Solution Sig: 4,000-11,000
units Injection PRN (as needed) as needed for line flush:
dialysis RN only.
21. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please wean off ___ ___ weeks.
23. CefazoLIN 2 g IV POST HD
on ___ and ___
___. CefazoLIN 3 g IV POST HD
On ___
___. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
26. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
27. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MSSA bacteremia
End stage renal disease on hemodialysis
Diabetes type 1
PEA arrest
Pericardial effusion
Pericarditis
Incidental nodule ___ lungs.
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: End-stage renal disease with weakness and vomiting, evaluate for
infection.
COMPARISONS: Chest radiographs dated ___ and ___.
AP AND LATERAL VIEWS OF THE CHEST: The lungs are clear, without focal
consolidation, pleural effusion, or pneumothorax. Cardiac silhouette is
enlarged, unchanged from prior study. Calcifications within the aortic arch
are seen.
IMPRESSION: No acute cardiopulmonary process. Stable cardiomegaly.
Radiology Report
CLINICAL HISTORY: ___ man with abdominal pain, vomiting, and fever.
End-stage renal disease.
COMPARISON: ___.
TECHNIQUE: CT of the abdomen and pelvis with IV contrast. No oral contrast
was administered.
FINDINGS: In the lung bases, there is a 1.1 x 6.0 cm nodule perifissurally in
the right lower lobe. There is no pericardial effusion or pleural effusion.
Within the abdomen, liver, gallbladder, spleen, and pancreas are all
unremarkable. Bilateral kidneys are atrophic in keeping with the patient's
end-stage renal disease. Hypodensities within the kidneys are consistent with
simple renal cysts, the largest off the upper pole on the right measuring 1.4
x 1.4 cm. Loops of bowel are collapsed, but show no evidence of abnormal
caliber or course. No evidence of abnormal enhancement is noted. There is
contrast material noted within the rectosigmoid colon. No abdominal
lymphadenopathy is noted. Calcifications are noted throughout the superior
mesenteric artery.
CT OF THE PELVIS: Bladder, prostate, and seminal vesicles are unremarkable.
No pelvic free fluid is noted.
BONES: No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. No evidence of intra-abdominal process to explain fevers.
2. 1.1-cm perifissural nodule in the right lower lobe. This is not clearly
identified on prior studies. Most likely, this is simply a subpleural lymph
node; however, given its size, followup scan in three months would be
recommended.
3. Atrophic kidneys in keeping with the patient's history of end-stage renal
disease.
Radiology Report
CLINICAL HISTORY: ___ man with end-stage renal disease with AV graft
and Gram-positive bacteremia, likely from the graft site. Evaluate for
vegetation, fluid collection, or abscess.
FINDINGS: Targeted ultrasound of the graft site in the right upper arm was
performed. Adjacent to the graft, there are three discrete collections with
homogeneous internal echoes, likely representing hematomas, at the superior,
mid, and distal portions of the graft. These are probably hematomas, possibly
due to graft access. The largest is at the inferior aspect, measuring 1.8 x
2.0 x 1.3 cm. No internal flow is documented within them. There is no
drainable fluid collection adjacent to the graft.
Within the lumen of the superior-mid portion of the graft, there is a small
3-mm, eccentric echogenic focus, which is flow diverting. This may represent a
small vegetation or thrombus.
IMPRESSION:
1. Three hematomas surrounding the graft, possibly related to graft access.
No evidence of abscess.
2. Small, eccentric intraluminal vegetation or thrombus within the
superior-to-mid portion of the graft.
Findings discussed with Dr. ___ by phone at 2:35 p.m., ___.
Radiology Report
INDICATION: ___ man with end-stage renal disease on hemodialysis, now
with MSSA bacteremia and an infected graft. Request for a left IJ tunneled
hemodialysis line.
COMPARISON: Tunneled dialysis line placement, ___.
RADIOLOGISTS: Dr. ___ (fellow), Dr. ___ (resident), and
Dr. ___ (Attending). Dr. ___, the attending
physician, supervised the procedure.
MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored
conscious sedation. The patient received a total quantity of 100 mcg of
fentanyl intravenously during the procedural time of 34 minutes, while the
patient's hemodynamic parameters and pulse oximetry were continually monitored
by a trained radiology nurse.
TECHNIQUE AND FINDINGS: Written informed consent was obtained after
explaining the risks, benefits, and alternatives of the procedure. The
patient was positioned on the angiography table in supine position and the
skin of the left anterior neck and left anterior chest wall was prepped and
draped in the usual sterile fashion. A preprocedure timeout was performed
according to the standard ___ protocol. Preprocedural ultrasound
demonstrated thrombosis of the lower half of the left internal jugular vein.
An initial attempt was made to cannulate the left internal jugular vein which
was unsuccessful. Following this, under ultrasound guidance and after
infiltration of the subcutaneous tissues with 1% lidocaine, left subclavian
vein above the level of the clavicle was punctured. Over a 0.018 inch
guidewire, a micropuncture needle was exchanged for a 4 ___ micropuncture
sheath followed by placement of a 0.035-inch ___ guidewire into the right
atrium. Calculation of the length of the tunneled hemodialysis line was made
and the ___ guidewire was reintroduced into the right atrium and advanced
into the inferior vena cava. Attention was then turned to the left anterior
chest wall. After generous infiltration of the subcutaneous tissues of the
left anterior chest wall with 1% lidocaine with and without epinephrine,
linear incision was made lateral to the subclavian venipuncture. Using blunt
preparation, soft tissue tunnel was created between the chest wall incision
and left internal jugular vein puncture site. A 27 cm long hemodialysis line
was pulled through the tunnel and advanced into the right atrium after
appropriate dilatation of the tract through the peel-away sheath which was
subsequently removed. The line was secured to the skin using 0 silk
stitches. Final radiograph demonstrates the tip of the line in the right
atrium. There was mild persistent oozing from the site of the tunnel, for
which approximately 2 cc of thrombin was injected to secure hemostasis. The
patient tolerated the procedure well and no immediate post-procedure
complications were present.
IMPRESSION: Ultrasound- and fluoroscopy-guided 15.5 ___ tunneled
hemodialysis catheter placement via left subclavian vein through a
supraclavicular approach, with the tip appropriately positioned within the
right atrium. The catheter is ready for use.
Radiology Report
INDICATION: Patient with end-stage renal disease, on hemodialysis, who now
presents with MSSA bacteremia, status post graft excision with recurrent
fevers. Assess for abscess formation.
COMPARISONS: ___.
FINDINGS:
Targeted ultrasound exam of the right arm at the site of the graft was
performed. Two of the heterogeneous collections seen on ___ exam, likely
hematomas, have resolved. A 2.4 x 1.3 x 2.1 cm heterogeneous collection
adjacent to the graft persists, essentially unchanged since prior study. It
is notable for internal calcifications and likely represent a chronic
hematoma.
IMPRESSION:
In comparison to ___ exam, two heterogeneous collections in the right
arm, likely hematomas, have resolved. A single heterogeneous collection
adjacent to the graft persists, likely a chronic hematoma, unchanged since
prior.
Radiology Report
HISTORY: ___ male with MSSA bacteremia and fevers, question acute
process.
COMPARISONS: ___.
FINDINGS: There has been interval placement of a left-sided hemodialysis
catheter, the tip of which projects over the right atrium. The cardiac
silhouette is moderately enlarged. There is no appreciable pulmonary edema.
There is no pleural effusion or pneumothorax.
IMPRESSION:
1. No evidence for pneumonia. There is moderate cardiomegaly, unchanged.
2. Interval placement of left IJ approach hemodialysis catheter, the tip of
which is projecting over the right atrium.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Persistent cough and fever, patient with pericarditis and
graft infection.
Comparison is made with prior study, ___.
Cardiomegaly is stable. Left HD catheter is in standard position. There is
no pneumothorax or pleural effusion. The lungs are grossly clear.
Radiology Report
AP CHEST, 3:43 A.M., ___
HISTORY: A ___ man with end-stage renal disease. Newly intubated,
following pericardiocentesis with a new right IJ temporary pacer lead.
IMPRESSION: AP chest compared to ___:
New heterogeneous opacification at the base of the right lung could be early
edema or pneumonia, since there has been only minimal increase in caliber of
the pulmonary vascular seen most clearly in the suprahilar right lung. Severe
cardiomegaly is chronic. Pleural effusion is small if any. No pneumothorax.
A wire or catheter projecting over the left axilla does not reach the left
chest. Dual-channel central venous line ends in the low SVC and right atrium.
A new pericardiocentesis catheter terminates along the diaphragmatic surface
of the heart. Temporary pacer lead runs from the right internal jugular to
the region of the tricuspid valve. The patient care unit was telephoned one
minute after recognition of these findings, but the patient is currently in
the OR.
Radiology Report
REASON FOR EXAMINATION: Pericardial effusion, bacteremia and new sinus node
dysfunction after PEA arrest.
AP radiograph of the chest was reviewed in comparison to ___.
External pacing electrodes were inserted in the interim. Pericardial drain is
in place. Hemodialysis catheter is in place. Cardiac silhouette and
mediastinal silhouettes are unchanged. Patient was extubated in the meantime
interval with removal of the NG tube. There is interval improvement in
pulmonary edema. No definitive pneumothorax is seen. Small amount of pleural
effusion is most likely present.
Radiology Report
INDICATION: ___ with persistent cough and known pulmonary nodules.
TECHNIQUE: Contiguous MDCT images through the chest were obtained without
intravenous contrast. Axial, coronal and sagittal reformats were acquired.
COMPARISON: CT of the chest from ___.
FINDINGS:
CT CHEST WITHOUT CONTRAST:
A hemodialysis catheter ends in the right atrium. There appears to be a
mid-line terminating in the region of the left axilla. There is mild
cardiomegaly.
External cardiac device electrodes are seen at the right atrium and right
ventricle. Mild subcutaneous air and air along the pericardium is likely
related to recent intervention. Again seen is a small-moderate pericardial
effusion, increased since ___ (pericardial window and pacemaker
placement performed ___.
There is a minimal left pleural effusion and bibasilar atelectatic changes,
less likely changes from aspiration.
A 3 x 9 mm subpleural nodule at the right base has decreased in size since
___, where it measured 6 x 11 mm. No concerning nodule or mass.
There is mild interseptal thickening, but no pulmonary edema.
There are no pathologically enlarged mediastinal, axillary or hilar lymph
nodes.
Fluid is seen in the mid esophagus, likely due to reflux.
BONES: There are no suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Small-to-moderate pericardial effusion, status post pericardial window and
pacemaker placement ___.
2. Bibasilar atelectatic changes, less likely aspiration.
3. Fluid in the mid esophagus, likely due to reflux.
4. Right basilar nodule has decreased in size since ___, presumably
represent a improving focus of atelectasis or infection.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: GENERALIZED WEAKNESS
Diagnosed with FEVER, UNSPECIFIED, ABDOMINAL PAIN OTHER SPECIED, HEMATEMESIS, END STAGE RENAL DISEASE
temperature: 98.2
heartrate: 79.0
resprate: 16.0
o2sat: 96.0
sbp: 148.0
dbp: 66.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ year old male with diabetes mellitus,
type 1 (DM1) complicated by end stage renal disease (ESRD) on
hemodialysis (HD) who initially presented with fevers and was
found to have Staph aureus bacteremia and infected AV Graft. He
underwent graft ligation and excision on ___. Hospital course
complicated by continued fevers and sinus arrest on telemetry
prompting transfer to the CCU on HD#8 for pericarditis. He
underwent pericardial drainage and epicardial pacemaker
placement on ___ after his sinus arrests did not improve
with conservative treatment of pericarditis.
# Methicillin-sensitive staph aureus (MSSA) AV graft infection:
Patient presented with fevers to 104 with rigors and
tachycardia. Blood cultures taken ___ ED immediately turned
positive for MSSA. He was transitioned from vancomycin to
cefazolin, dosed with HD. Initial TTE was negative for
endocarditis and repeat TEE on ___ was also negative for
endocarditis or abscess. Ultrasound of graft showed possible
focus of infection. Transplant surgery took patient to OR on ___
for graft excision which per report was found to have frank pus.
Majority of graft was removed however part of it remains. Wound
was packed and no longer drained purulent material. ID was
consulted who suggested 6 weeks of therapy with cefazolin given
retained foreign object from graft. Patient had a line holiday
from ___ to ___. On ___ (HD#6) patient had tunnelled line
placed by ___. That night, patient spiked a fever to 101 however
was asymptomatic. Repeat ultrasound did not reveal abscess. On
___ he continued to spike fevers. On ___, he was noted to have
a new friction rub. EKG showed new Q waves anterolaterally.
Cardiology was consulted who suggested transfer to cardiology
for further management of pericarditis (see below). He was
treated with cefazolin x 6 weeks dosed for HD on 2gm/2gm/3gm
daily on ___. He is set up for ID outpatient follow up and
should have weekly labs: CBCw/diff, CMP, fax to ___.
# Bradycardia with sinus arrest: He developed bradycardia with
HR ranging from the ___ to the ___ resting. Several provocative
vagal maneuvers and administration of atropine failed to improve
the bradycardia, indicating that it was unlikely an AV nodal
problem. He had EKGs back to ___ showing prolonged PR interval
never longer than 240. He again went into various sinus node
arrhythmias such as sinus exit block, sinus bradycardia, sinus
Wenckebach block, and sinus arrests with pauses up to 5 seconds.
He did have drops ___ his blood pressure with these sinus
arrests and occasionally was observed to have seizure activity
by the dialysis nurses.
He was started on a dopamine drip, however, it stopped
working after about 18 hours. Because of concern for
hemodynamic instability with pauses, he was started on
isoproterenol with good response of his heart rate and
improvement ___ pauses and blood pressures. The EP team felt
that his new arrhythmias may have been related to pericardial
effusion (see below) so he was tried on colchicine and ibuprofen
(renally dosed). This did not improve his arrhythmias. He was
also tried on PO theophylline and glycopyrollate without
improvement ___ bradycardia or arrhythmias.
On ___, he complained of intense pruritus and vomiting
with drop ___ his blood pressure to ___, despite fluid boluses.
He was started on pressors and a bedside echo showed enlargement
of his pericardial effusion with possible tamponade physiology.
During the echo, he was observed to be bradycardic to the ___
with myoclonic jerks and then became pulseless. He underwent
chest compressions and received 1 amp of epinephrine which
regained pulse. Also gave 125 solumedrol for possible
anaphylaxis given prurtitus, low BP and vomiting. He went to
the cath lab for emergent temporary transvenous pacemaker
placement through his right IJ. On ___ cardiac surgery placed
a permanent epicardial pacemaker with pericardial drainage, his
generator is ___ his abdomen. This was chosen because of the
lower risk for infection while bacteremic and because he already
had many venous access problems ___ his upper extremities and
thorax for HD.
# Pericardial effusion: At the same time that he developed the
bradycardias, he also started to become febrile again and had a
new physical exam finding of pericardial rub. An echo showed a
trace effusion, which had developed ___ the interval from ___ to
___. Repeat echo on ___ showed slight interval enlargement
of the pericardial effusion and then on ___ there was concern
for tamponade as above (pressures during the cath did not
indicate tamponade physiology). He has ESRD and his uremia
worsened to 100 on ___ so the effusion could have been uremic
pericarditis. However, he also was febrile again with a known
recent blood stream infection so it is possible that the
pericardial fluid was infected. Cultures of the fluid was
negative on discharge.
# DM1: His diabetes was managed with sliding scale insulin and
glargine.
# ESRD on HD: As above, patient had infected graft which was
removed on ___. Tunnelled line was placed on ___. Patient
continued on regular ___ schedule. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefpodoxime
Attending: ___.
Chief Complaint:
FN
Major Surgical or Invasive Procedure:
PiCC placement and removal prior to discharge
History of Present Illness:
Ms. ___ is a ___ year-old female with AML (diagnosed ___
with AML, normal karyotype, mutations in IDH2, SRSF2, and ASXL1,
enrolled on clinical trial protocol ___: a randomized Phase
II clinical trial of Dendritic Cell/AML fusion cell vaccine
versus DC/AML fusion cell vaccine in conjunction with
durvalumab, versus observation, in patients who achieve a
chemotherapy-induced remission, status-post decitabine x 5
cycles, in morphologic remission) and sub-segmental pulmonary
emboli (treated initially with therapeutic anticoagulation,
ultimately held with significant right gluteal hematoma, with
IVC filter in situ since ___, anticoagulation stopped last
admission), and right gluteal hematoma following bone marrow
biopsy (now resolved) with 2 recent admissions.
She was here ___ for relapsed AML, MDR UTI and C diff and
admitted again ___ for febrile neutropenia. She was treated
with
___ and then transtioned to prophylactic levaquin. No
definite source could be identified and she was discharged
yesterday.
Now she is admitted again due to fever. After getting discharged
yesterday afternoon, she was feeling well till this morning when
she felt unwell. She took her temperature and it was 99 and
eventually climbed upto 101.2. a/w chills. No new complaints
since the discharge but she does reports stuffy nose, dry cough
for past few days. She also has chronic diarrhea now after
C.diff
infection and has ___ loose BMs/day. She has no urinary
complaints. No dyspnea but was noted to be hypoxic in ED and
placed on nasal cannula oxygen. no ear pain. no headache. no
rash. no port/picc lines.
Past Medical History:
ONCOLOGIC AND TREATMENT HISTORY (PER OMR):
==========================================
- ___: Presented to ___ with weakness,
cough, and shortness of breath, and was found to have
neutropenia
with 17% peripheral blasts. Was also found to have subsegmental
pulmonary emboli and multifocal pneumonia.
- ___: Transferred to ___. Bone marrow biopsy revealed
AML with blasts comprising 40-50% of overall marrow cellularity.
Rapid heme panel revealed mutations in IDH2, SRSF2, and ASXL1.
- ___: Screened and consented for ___ ___, a
randomized phase II clinical trial of dendritic cell/AML fusion
cell vaccine vs. DC/AML fusion cell vaccine in conjunction with
durvalumab vs. observation in patients who achieve a
chemotherapy-induced remission.
- ___: Developed large right gluteal hematoma.
- ___: C1D1 decitabine 20 mg/m2 for 10 days.
- ___: Anticoagulation discontinued and IVC filter placed
for right gluteal hematoma evolution.
- ___: Skin biopsy with histiocytic Sweet syndrome.
Resolved with topical corticosteroids.
- ___: C2D1 decitabine 20 mg/m2 for 10 days.
- ___: C3D1 decitabine 20 mg/m2 for 10 days.
- ___: Peripheral blasts cleared.
- ___: Episode of vasovagal syncope during defecation.
Positive head strike. CT head without evidence of intracranial
fracture, hemorrhage, or infarction.
- ___: Discharged home.
- ___: Bone marrow biopsy with maturing trilineage
hematopoiesis and no overt evidence of involvement by leukemia.
Flow cytometry with 6% blasts.
- ___: C4D1 decitabine 20 mg/m2 for 5 days.
- ___: Bone marrow biopsy with maturing trilineage
hematopoiesis and no overt evidence of involvement by leukemia.
Flow cytometry with 4% blasts.
- ___: Randomized to observation on ___ ___.
- ___: C5D1 decitabine 20 mg/m2 for 5 days.
PAST MEDICAL HISTORY (PER OMR):
===============================
-AML, as above
-DCIS s/p lumpectomy in ___. No chemotherapy or radiotherapy.
-GERD
-Colonic polyps (___)
-Folate deficiency
-Alcohol use
Social History:
___
Family History:
Father with prostate cancer. Sister with breast
cancer and depression.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7PO 109 / 61 73 20 94 2L
GENERAL: Pleasant, siting in bed comfortably
HEENT: Sclera anicteric, MMM, no mucosytis, PERRLA, EOMI
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Breathing comfortably on room air, crackles in bilateral
bases, no wheezes.
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PE:
VS T 98.3 BP 114/60 HR 77 RR 18 O2 99%
GENERAL: no acute distress, siting in bed, comfortable
HEENT: Sclera anicteric, MMM, no OP lesions. PERRLA, EOMI
CARDIAC: RRR, no murmurs, rubs, or gallops
LUNG: no distress, bibasilar crackles
ABD: NT/ND. +BS. No HSM/palpable masses
EXT: WWP, no lower extremity edema
NEURO: A/O x3, CN II-XII intact, motor and sensory function
grossly intact
SKIN: Multiple old bruising on upper extremities. maculopapular
erythematous patches on upper/lower extremities b/l resolved.
Pertinent Results:
ADMISSION LABS:
___ 12:00AM BLOOD WBC-1.7* RBC-2.63* Hgb-8.1* Hct-25.1*
MCV-95 MCH-30.8 MCHC-32.3 RDW-20.6* RDWSD-71.4* Plt Ct-17*
___ 12:00AM BLOOD Neuts-4* Bands-0 Lymphs-62* Monos-8 Eos-6
Baso-0 ___ Myelos-0 Blasts-20* AbsNeut-0.07*
AbsLymp-1.05* AbsMono-0.14* AbsEos-0.10 AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-123* UreaN-10 Creat-0.7 Na-140
K-3.6 Cl-104 HCO3-23 AnGap-13
___ 12:00AM BLOOD ALT-49* AST-49* LD(LDH)-357* AlkPhos-180*
TotBili-1.5
___ 12:00AM BLOOD Albumin-2.7* Calcium-7.4* Phos-3.6 Mg-1.8
UricAcd-4.4
DISCHARGE LABS:
___ 12:00AM BLOOD WBC-4.3 RBC-2.59* Hgb-7.6* Hct-23.5*
MCV-91 MCH-29.3 MCHC-32.3 RDW-16.7* RDWSD-53.7* Plt Ct-11*
___ 12:00AM BLOOD Neuts-63 Bands-0 ___ Monos-8 Eos-2
Baso-0 ___ Myelos-0 Blasts-3* AbsNeut-2.71
AbsLymp-1.03* AbsMono-0.34 AbsEos-0.09 AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-104* UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-102 HCO3-23 AnGap-15
___ 12:00AM BLOOD ALT-54* AST-46* LD(LDH)-625* AlkPhos-191*
TotBili-0.9
___ 12:00AM BLOOD Albumin-3.2* Calcium-7.6* Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. enasidenib 100 mg PO DAILY
4. Omeprazole 20 mg PO QPM
5. Posaconazole Delayed Release Tablet 300 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Vancomycin Oral Liquid ___ mg PO QID
8. Vitamin D 1000 UNIT PO DAILY
9. Levofloxacin 500 mg PO Q48H
Discharge Medications:
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. DiphenhydrAMINE 12.5 mg PO BID:PRN itching
3. Sarna Lotion 1 Appl TP QID:PRN itching
4. Vancomycin Oral Liquid ___ mg PO QID
5. Acyclovir 400 mg PO Q12H
6. enasidenib 100 mg PO DAILY
7. Omeprazole 20 mg PO QPM
8. Thiamine 100 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Levofloxacin 500 mg PO Q48H This medication was held.
Do not restart Levofloxacin until outpatient team tells you to
do so, currently do not need because your blood counts recovered
11. HELD- Posaconazole Delayed Release Tablet 300 mg PO DAILY
This medication was held. Do not restart Posaconazole Delayed
Release Tablet until outpatient team tells you to do so.
currently do not need because blood counts recovered
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
leukemia
differentiation syndrome
febrile neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fever// ?pna
TECHNIQUE: Small bilateral pleural effusions and pulmonary vascular
congestion. No focal consolidation
COMPARISON: Chest x-ray from ___.
FINDINGS:
Prior left PICC is no longer visualized. There are small bilateral pleural
effusions and mild vascular congestion. Retrocardiac opacity is compatible
with a hiatal hernia. There is no focal consolidation or pulmonary edema.
Cardiomediastinal silhouette is stable. No acute osseous abnormalities.
IMPRESSION:
Small bilateral pleural effusions. No focal consolidation.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated LFTs// etiology of elevated Bili
and liver enzymes
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound ___
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 small volume perihepatic and perisplenic
ascites, new from prior. Probable trace right pleural effusion is
incidentally noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: Gallbladder is mildly distended with layering gallbladder sludge
noted. There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas is notable for a 8 hypoechoic
lesion in the head of the pancreas that measures 0.6 x 0.3 x 0.4 cm, similar
compared to prior.
SPLEEN: Normal echogenicity, measuring 8.0 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Persistent mild distention of the gallbladder which contains gallbladder
sludge without evidence of cholecystitis.
2. New small volume perihepatic and perisplenic ascites.
3. No significant change in 0.6 cm hypoechoic lesion in the head of the
pancreas which can be further evaluated with MRCP.
4. Incidentally noted probable trace right pleural effusion.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with concern of differentiation syndrome due to
AML treatment// r/o infection vs effusion/edema
TECHNIQUE: Multidetector helical scanning of the chest performed without
intravenous 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: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 32.4 cm; CTDIvol = 6.7 mGy (Body) DLP = 217.6
mGy-cm.
Total DLP (Body) = 218 mGy-cm.
COMPARISON:
1. Chest x-ray ___.
2. CT chest ___ and ___.
FINDINGS:
The thyroid is unremarkable. Esophagus is grossly within normal limits, not
well evaluated on this exam. There is a moderate sized hiatus hernia, similar
to prior. The pulmonary artery is normal in caliber. Mild aortic valvular
calcifications are unchanged. Mild aortic arch calcifications are also
unchanged. The pulmonary artery is top normal measuring up to 3.5 cm in
diameter, unchanged. Heart is normal with respect size. There is minimal
coronary artery calcification. No pericardial effusion. Diffuse
hypoattenuation of the blood pool, which can be seen in the setting of anemia.
Scattered mediastinal lymph nodes are not individually enlarged and retain
normal morphology, likely reactive (e.g. see series 4, image 103 for a 10 mm
low right paratracheal station lymph node). There are no pathologically
enlarged mediastinal, discernible hilar, axillary, or subpectoral lymph nodes.
Supraclavicular lymph nodes are slightly numerous but not individually
enlarged.
Major airways are patent bilaterally. There are small bilateral layering
pleural effusions. There is diffuse, soft hazy ground glass attenuation the
lung parenchyma. There are multiple bilateral, right more numerous than left
peripheral/subpleural sub 5 mm pulmonary nodules. While some of these are
unchanged compared with prior exam of ___ (for example 04:41, 54,
77, 113), numerous additional sub-5 mm nodules are new or newly apparent (for
example see series 4 images 53, 76, 67, 72, and 60). There unchanged sub-5 mm
calcified granulomas seen in the right lower lobe (4:76 and 209). There is no
new focal lung consolidation. There is bibasilar dependent subsegmental
atelectasis adjacent to the pleural effusions. No pneumothorax.
Postprocedural changes are seen along the right anterior chest wall, as on
prior. Otherwise, no focal abnormality within the imaged soft tissues of the
chest wall. Moderate bilateral glenohumeral osteoarthritis is noted. No
concerning focal lytic or sclerotic osseous lesions are seen.
IMPRESSION:
1. Bilateral layering small pleural effusions with diffuse, hazy ground-glass
lung parenchymal attenuation, which could represent pulmonary edema, however
differentiation syndrome could have a similar appearance. No focal lung
consolidation.
2. Multiple new or newly apparent bilateral subpleural sub-5 mm pulmonary
nodules which are non-specific. Other bilateral sub-5 mm solid pulmonary
nodules are unchanged since study of ___. Attention to these on
follow-up studies.
3. Scattered prominent likely reactive mediastinal lymph nodes.
4. Subsegment bibasilar atelectasis.
5. Large hiatus hernia.
6. Unchanged right anterior chest wall postprocedural changes, likely related
to prior lumpectomy.
7. Moderate bilateral glenohumeral osteoarthritis. Other incidental findings,
as above.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with PICC// Pt had a L PICC,42cm ___ ___
Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph ___
FINDINGS:
There has been interval placement of a left PICC line which is seen to coiled
back upon itself in the left subclavian vein. Compared to the prior
radiograph, the mild pulmonary vascular congestion appears improved. Small
bilateral pleural effusions appear stable. No pneumothorax. The cardiac
silhouette is within normal limits.
IMPRESSION:
Left PICC line coils on itself in the left subclavian vein and should be
retracted and readvanced.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 1:46 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with failed bedside PICC placement// PICC
placement please
COMPARISON: Chest radiograph on ___
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology 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: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: Lidocaine
CONTRAST: ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.4 min, 5 mGy
PROCEDURE: 1. Repositioning of left PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
double lumen PIC line measuring 40 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing left arm approach PICC with tip looped in the subclavian replaced
with a new double lumen PIC line with tip in the distal SVC.
IMPRESSION:
Successful placement of a 40 cm left arm approach double lumen PowerPICC with
tip in the distal SVC. The line is ready to use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 100.6
heartrate: 90.0
resprate: 15.0
o2sat: 88.0
sbp: 142.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year-old female with AML
s/p 6C of Decitabine now with relapsed AML for which she is on
Enasidenib, ___ inhibitor. Recent admission for C-diff and MDR
E-coli UTI and then re-admission for febrile neutropenia. Now
admitted again with FN, concern of differentiation syndrome,
ongoing pancytopenia and transaminitis. New rash as of ___ now
resolving. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Ampicillin / Penicillins / Banana
Attending: ___.
Chief Complaint:
Trauma: pedestrian struck
Major Surgical or Invasive Procedure:
___: suture of laceration right brow
History of Present Illness:
___ year old gentleman who presented as a pedestrian struck. He
was
walking down the street and was struck by a car going ___
mph. He was brought to the ___. He underwent a
CT of his head, cspine, torso. His injuries show a left
subfrontal SAH, multiple facial abrasions, facial
lacerations, left orbital fracture. He was given keppra,
Ativan, clindamycin, fentanyl. He has a history of daily
alcohol use. He complains of headache, posterior neck pain,
left knee pain. He takes a baby aspirin. No anticoagulation
use.
Past Medical History:
#EtOH Abuse/Dependence:
- reports daily use x ___ years
- reported withdrawal seizures
- no known DTs
#PSA:
- IVDU: heroin, cocaine
#Endocarditis:
- ___ MSSA; c/b TR
#Depression: hx cutting and SA; several prior hospitalizations,
previously treated w/ quetiapine, buproprion
#Anxiety
#Chronic pain
#Atypical chest pain
HOME MEDS:
Gabapentin 600mg 4XD
Ipratropium
Omeprazole 20
Sertraline 50mg
Thiamine
Amlodipine 10mg
Folic acid
Social History:
___
Family History:
+EtOH abuse / alcoholism "everyone in the family except my
mother"
Physical Exam:
PHYSICAL EXAMINATION
HR: 92 BP: 147/82 O(2)Sat: 98 Normal
Constitutional: Comfortable
HEENT: right hemotympanum, no hemotypanum on the left.
pupils 2mm and reaction. forehead laceration with 3 sutures
in place. right orbit with swelling. left eye does not open
spontaneously. epistaxis from bilateral nares. dried blood
in mouth. several front teeth missing
c-collar in place
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffuse tenderness
Extr/Back: tenderness to the bilateral shoulders. left knee
tender. pelvis stable
Skin: superficial abrasion to left knee
Neuro: tremulous, sensory and motor intact, responding to
questions appropriately
Physical examination upon discharge: ___:
vital signs: 98.9, hr=98, bp=104/66, rr=18, 99% room air
GENERAL: NAD, ambulatory in hallway
HEENT: sutures left medial brow, facial ecchymosis
CV: n1, 2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non tender, no rebound
EXT: no pedal edema bil., subungal hemorrhage left thumb, no
calf tenderness
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:21AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.4* Hct-25.0*
MCV-98 MCH-32.8* MCHC-33.6 RDW-12.0 RDWSD-42.6 Plt ___
___ 01:47AM BLOOD WBC-8.1 RBC-2.61* Hgb-8.7* Hct-26.1*
MCV-100* MCH-33.3* MCHC-33.3 RDW-12.2 RDWSD-44.7 Plt ___
___ 10:30AM BLOOD WBC-6.6 RBC-4.16* Hgb-13.4* Hct-39.6*
MCV-95 MCH-32.2* MCHC-33.8 RDW-12.9 RDWSD-45.2 Plt Ct-84*
___ 05:21AM BLOOD Plt ___
___ 05:21AM BLOOD Glucose-120* UreaN-7 Creat-0.7 Na-131*
K-3.7 Cl-93* HCO3-30 AnGap-12
___ 01:47AM BLOOD Glucose-86 UreaN-6 Creat-0.6 Na-132*
K-3.7 Cl-96 HCO3-29 AnGap-11
___ 02:16AM BLOOD ALT-278* AST-277* AlkPhos-74 TotBili-1.1
___ 10:30AM BLOOD Lipase-109*
___ 05:21AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
___ 10:30AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___ 10:37AM BLOOD ___ pH-7.38 Comment-GREEN TOP
___ 10:37AM BLOOD Glucose-100 Lactate-1.3 Na-140 K-3.8
Cl-102 calHCO3-24
___ 10:37AM BLOOD Hgb-14.4 calcHCT-43 O2 Sat-93 COHgb-6*
MetHgb-0
___ 10:37AM BLOOD freeCa-1.02*
___: CT of the head:
1. Extremely limited examination due to motion artifact. Within
these
limitations, the inferior left frontal intra-parenchymal
hemorrhage has
increased in size, currently measuring up to 2.5 cm. No
significant mass
effect or midline shift.
2. The known bilateral facial bone fractures are not well
demonstrated on this examination.
3. Radiopaque foreign object within the subcutaneous tissues
overlying the
right frontal bone.
___: CT sinus:
1. Multiple left facial fractures with a left intra-orbital
extraconal
hematoma.
2. Multiple left cribriform plate fractures
3. Bilateral displaced nasal bone fractures.
4. Fluid in the left maxillary sinus suggests a non-displaced
fracture,
although none is identified on this examination.
___: left knee:
No acute fractures or dislocations are seen. There is no knee
joint effusion.
Joint spaces are preserved without significant degenerative
changes. There is normal osseous mineralization. There is a 0.4
mm metallic density within the medial soft tissues of the lower
thigh. This may represent a foreign body.
___: left hand:
No acute fractures or dislocations are seen. There are mild
degenerative
changes of the triscaphe joint. There is normal osseous
mineralization. There are no erosions. No focal lytic or
blastic lesions are present. There are no abnormal soft tissue
calcifications.
___: ct head:
1. Stable left frontal intra-parenchymal hemorrhage with
slightly increased surrounding edema. No evidence of new
hemorrhage.
2. Multiple facial fractures better evaluated recent CT sinus.
3. Stable left orbital hematoma displacing the superior rectus
muscle.
4. Foreign body within the subcutaneous soft tissue overlying
the right
frontal bone.
___: ct head:
. Study is mildly degraded by motion.
2. Grossly stable bifrontal intraparenchymal hemorrhage with
surrounding
edema.
3. Grossly stable facial bone fractures and left extraconal
orbital hematoma better evaluated on recent maxillofacial CT.
___: MR cervical spine:
. No evidence of ligamentous injury or paraspinal soft tissue
abnormality. There is no pre-vertebral edema. No cord signal
abnormality.
2. Mild degenerative changes of the cervical spine, most
prominent at C5-C6 and C6-C7 where disc protrusions and
intervertebral osteophytes results in mild spinal canal
narrowing. Uncovertebral and facet arthropathy results in
moderate to severe right and moderate left neural foraminal
narrowing at C6-C7.
3. The disc protrusions at C5-C6 and C6-C7 is felt to be most
likely
degenerative in nature in given associated osteophytes and
uncovertebral facet arthropathy seen on outside hospital CT.
Radiology Report
EXAMINATION: Single portable AP radiograph of the chest.
INDICATION: History: ___ with hypoxic, trauma // ? acute process
TECHNIQUE: AP radiograph of the chest.
COMPARISON: CT chest from the outside hospital with the same date.
FINDINGS:
Lungs are well-expanded and clear. No focal consolidations. No pulmonary
edema. Normal appearance of the cardiomediastinal silhouette. No pleural
effusion. No pneumothorax. No acute osseous abnormalities.
IMPRESSION:
Normal chest radiograph.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ s/p MVA with facial Fx now mental status
deteriorating // Brain Inj, ICH?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 4.2 cm; CTDIvol = 47.9 mGy (Head) DLP =
200.7 mGy-cm.
2) Sequenced Acquisition 14.0 s, 14.7 cm; CTDIvol = 47.9 mGy (Head) DLP =
702.4 mGy-cm.
3) Sequenced Acquisition 3.0 s, 6.3 cm; CTDIvol = 47.9 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: CT head from outside hospital dated ___ peer
FINDINGS:
This examination is limited by motion artifact.
The inferior left frontal intraparenchymal hemorrhage has increased in size,
currently measuring 2.5 x 1.6 x 1.2 cm. There is no significant mass effect
or midline shift. The basal cisterns are patent. There is no evidence of
acute territory infarction,edema, or mass. The ventricles and sulci are
normal in size and configuration.
Soft-tissue swelling and subcutaneous air overlying the bilateral frontal
bones and left orbit. There is also a radiopaque foreign object within the
subcutaneous tissues overlying the right frontal bone (series 3, image 36).
The known bilateral facial bone fractures are not well demonstrated on this
examination. There is high-density fluid layering within the left frontal and
maxillary sinuses, likely hemorrhage. The visualized portion of the mastoid
air cells and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Extremely limited examination due to motion artifact. Within these
limitations, the inferior left frontal intraparenchymal hemorrhage has
increased in size, currently measuring up to 2.5 cm. No significant mass
effect or midline shift.
2. The known bilateral facial bone fractures are not well demonstrated on this
examination.
3. Radiopaque foreign object within the subcutaneous tissues overlying the
right frontal bone.
Radiology Report
INDICATION: History: ___ s/p mva // Fx?
COMPARISON: None.
IMPRESSION:
No acute fractures or dislocations are seen. There are mild degenerative
changes of the triscaphe joint. There is normal osseous mineralization.There
are no erosions. No focal lytic or blastic lesions are present. There are no
abnormal soft tissue calcifications.
Radiology Report
INDICATION: History: ___ s/p mva // Fx?
IMPRESSION:
No acute fractures or dislocations are seen. There is no knee joint effusion.
Joint spaces are preserved without significant degenerative changes. There is
normal osseous mineralization.There is a 0.4 mm metallic density within the
medial soft tissues of the lower thigh. This may represent a foreign body.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ w/ethmoid fx and left orbital fx at OSH, please eval for
additional facial fractures*** WARNING *** Multiple patients with same last
name!
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 2.0 s, 15.9 cm; CTDIvol = 25.3 mGy (Head) DLP = 402.3
mGy-cm.
Total DLP (Head) = 402 mGy-cm.
COMPARISON: CT head with the same date.
FINDINGS:
There are bilateral displaced nasal bone fractures and a fracture and leftward
deviation of the septum. There is a fracture through the anterior and
posterior walls of the left frontal sinus and orbital roof. There are
fractures of the medial orbital wall with retrobulbar intra-orbital air
extending from the ethmoid sinus. The sagittal images demonstrate multiple
fractures along the left cribriform plate. Although no fracture is identified
involving the left maxillary sinus, the presence of aerosolized fluid within
the sinus suggests a nondisplaced fracture may be present.
There is soft tissue hemorrhage, swelling and subcutaneous emphysema overlying
the left orbit.
There is a large superior and medial left orbital hematoma causing inferior
and lateral displacement of the superior rectus muscle. There is partial
opacification with air-fluid levels involving the left frontal, maxillary, and
ethmoid sinuses, likely hemorrhage. The mastoid air cells are clear.
Again seen and better displayed on the head CT is a left inferior frontal lobe
hemorrhage, presumably a hemorrhagic contusion.
IMPRESSION:
1. Multiple left facial fractures with a left intraorbital extraconal
hematoma.
2. Multiple left cribriform plate fractures
3. Bilateral displaced nasal bone fractures.
4. Fluid in the left maxillary sinus suggests a nondisplaced fracture,
although none is identified on this examination.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man ___ s/p MVC // ? enlarging ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.3 cm; CTDIvol = 49.4 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast CT head ___ 10:36, and ___ 80
08:23
FINDINGS:
There is a stable appearance of the left frontal intraparenchymal hemorrhage,
measuring up to 2.7 cm. There appears to be an increased amount of
surrounding vasogenic edema. There is no significant mass effect. Basal
cisterns are patent. No new hemorrhage is identified. There is no evidence
of infarction. An increased amount of bifrontal low-density extra-axial fluid
may represent subdural hygromas. The ventricles and sulci are normal in size
and configuration.
There is soft tissue swelling surrounding the left orbit. Nasal bone
fractures and septal deviation again appreciated and better evaluated on
recent CT sinus. High-density fluid in the left maxillary sinus likely
represents hemorrhage. There is also fluid in the right maxillary sinus and
mucosal thickening of the ethmoidal air cells and left sphenoidal sinus. The
mastoid air cells are clear. The left superior medial orbital hematoma is
stable and continues to displace the superior rectus muscle. There is a
subcutaneous radiopaque foreign body with surrounding the soft tissue
overlying the right frontal bone.
IMPRESSION:
1. Stable left frontal intraparenchymal hemorrhage with slightly increased
surrounding edema. No evidence of new hemorrhage.
2. Multiple facial fractures better evaluated recent CT sinus.
3. Stable left orbital hematoma displacing the superior rectus muscle.
4. Foreign body within the subcutaneous soft tissue overlying the right
frontal bone.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SAH and contusion. Evaluate for
intracranial hemorrhage stability.
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 18.0 s, 18.9 cm; CTDIvol = 47.7 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.2 cm; CTDIvol = 47.7 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: ___ noncontrast head CT.
___ noncontrast maxillofacial CT
FINDINGS:
Study is mildly degraded by motion. There is expected evolution of the known
left frontal intraparenchymal hemorrhage with slight interval decrease in size
measuring 2.6 cm (previously, 2.7 cm) and stable appearance of surrounding
edema with no significant mass effect. Grossly stable punctate right punctate
probable intraparenchymal hemorrhage is again noted (see 601b:40 on current
study and 601b:36 on ___ prior exam).
There is no midline shift and the basal cisterns appear patent. No change in
the bifrontal low-density fluid collections which may represent subdural
hygromas or chronic subdural hematomas. There is no evidence of infarction.
Previously described nasal bone fractures are again appreciated. There
appears to be less fluid in the left maxillary sinus and a stable amount of
fluid in the right maxillary sinus compared to yesterday's exam. There is
opacification of the ethmoidal air cells, increased since yesterday's exam.
The visualized portions of the mastoid air cells and middle ear cavities are
clear. The extraconal left orbital hematoma appears stable to slightly
decreased. Radiopaque foreign body is again seen in the subcutaneous soft
tissue overlying the right frontal bone.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Grossly stable bifrontal intraparenchymal hemorrhage with surrounding
edema.
3. Grossly stable facial bone fractures and left extraconal orbital hematoma
better evaluated on recent maxillofacial CT.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ male with cervical spine tenderness status post
trauma. Assess for ligamentous or soft tissue injury.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: ___ MR cervical spine. Outside hospital CT head,
maxillofacial and cervical spine of ___.
FINDINGS:
Cervical alignment is anatomic. The vertebral body heights are preserved.
There is slight loss of intervertebral disc space at C5-C6 and C6-C7 levels.
There is no suspicious marrow replacing lesion or definite evidence of
fracture, although CT is a more sensitive means for evaluation. Minimal
T2/STIR hyperintense signal along the left aspect of the C6 and C7 vertebral
bodies is identified, which may represent marrow edema, likely degenerative in
nature given the presence of intervertebral and uncovertebral osteophytes on
prior CT. The anterior and posterior longitudinal ligaments, ligamentum
flavum as well as interspinous ligaments appear unremarkable.
C2-C3 through C4-C5 levels: There is no high-grade spinal canal stenosis or
significant neural foraminal narrowing.
C5-C6: There is a central and left paracentral disc protrusion and mild
intervertebral osteophytes results in mild spinal canal narrowing with minimal
remodeling of the left ventral aspect of the cord. Uncovertebral and facet
arthropathy results in mild bilateral neural foraminal narrowing.
C6-C7: A central disc protrusion with intervertebral osteophytes results in
mild spinal canal narrowing with minimal remodeling of the cord.
Uncovertebral and facet arthropathy results in moderate to severe right and
moderate left neural foraminal narrowing.
C7-T1: There is no high-grade spinal canal stenosis or significant neural
foraminal narrowing.
The prevertebral soft tissues appear unremarkable.
IMPRESSION:
1. No evidence of ligamentous injury or paraspinal soft tissue abnormality.
There is no prevertebral edema. No cord signal abnormality.
2. Mild degenerative changes of the cervical spine, most prominent at C5-C6
and C6-C7 where disc protrusions and intervertebral osteophytes results in
mild spinal canal narrowing. Uncovertebral and facet arthropathy results in
moderate to severe right and moderate left neural foraminal narrowing at
C6-C7.
3. The disc protrusions at C5-C6 and C6-C7 is felt to be most likely
degenerative in nature in given associated osteophytes and uncovertebral facet
arthropathy seen on outside hospital CT.
Radiology Report
INDICATION: ___ year old man with right wrist pain s/p ped struck // ?
fracture dislocation
COMPARISON: None of the right hand.
IMPRESSION:
No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. There is normal osseous
mineralization.There are no bony erosions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with Oth fracture of base of skull, init for clos fx, Traum subdr hem w/o loss of consciousness, init, Ped on foot injured pick-up truck, pk-up/van in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 10
level of acuity: nan | ___ year old male with a history of alcohol abuse, HepC, HepB,
prior IVDA and endocarditis who was struck by car going while
walking to work. He reportedly was struck from behind. There
was a reported loss of consciousness at the scene. He was
evaluated at an OSH where imaging was done. He was reported to
have a left SAH, left orbital floor, zygomatic arch, and nasal
bone fractures.
Upon arrival in the emergency room, he was alert and oriented x
3 with a GCS of 15. He became minimally responsive after 10mg
valium given for concern for alcohol withdrawal. A head CT
showed enlargement of the SAH from the outside imaging. The
Neurosurgery service was consulted for evaluation. The patient
was admitted to the intensive care unit for neurological
examination and blood pressure monitoring. He was started on a
phenobarbital taper because of his history of alcohol abuse.
While in the intensive care unit, the patient's neurological
status remained stable. He was given 1 unit of platelets for a
platelet count of 84,000 and was started on Keppra for seizure
prevention. Because of the facial injuries, the Plastic surgery
and Optholomology services were consulted. The patient was
reported to have brisk oozing of blood from the left nares and
packing was inserted. The packing was later removed by the
patient but was replaced by the Plastic surgery service. It was
later removed without recurrence of nasal bleeding. Because of
the extent of the facial injuries there was concern for
meningitis and the patient was started on a 3 day course of
meropenum for meningitis prophalxsis and placed on sinus
precautions. The Ophthalmology sevice was consulted to rule out
intraocular globe injury. From there examination, there was no
evidence of optic nerve compromise and no acute optic nerve
changes.
The patient was transferred to the surgical floor on HD #3. He
remained in the ___ collar because he continued to report
neck pain. He underwent an MRI which showed no evidence of
ligamentous injury or para-spinal soft tissue abnormality and
the collar was removed on HD #5. The patient continued on his
phenobarbital taper, but did require occasional doses of Haldol
for delirium. The patient's neurological status remained
stable. In preparation for discharge, the patient's mobility
status was evaluated by physical therapy and cognitive function
addressed by occupational therapy. After a few sessions, the
patient was cleared for discharge home. He was ambulatory
without the assistance of support. Neurology was consulted on
___ for recurrence of headaches. Both environmental and
medical measures were outlined. The patient was started on a
course of amitriptyline. After initiation of these measures,
the severity of the headache decreased, but was still present.
The patient was cleared for discharge home with ___ services on
___. At the time of discharge, his vital signs were stable and
he was afebrile. He was tolerating a regular diet and voiding
without difficulty. His hematocrit stabilized at 25 with a
platelet count of 109,000. He was ambulatory without mechanical
or physical support. Appointments for follow-up were made with
the Plastic surgery service and with his primary care provider.
Discharge instructions were reviewed and questions answered.
**************
Of note, patient non-compliant with home medications and
uncertain as to what he takes. Recommend med review with PCP |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
___ - Coronary angiogram
History of Present Illness:
___ w/ severe AS (bicuspid, ___ 0.7,
MG 33, vel 3.5), HFrEF (EF 30%), HTN, HLD, IDDM, OSA, metastatic
breast CA admitted following syncopal event, concerning for
cardiogenic syncope ___ valvular disease.
Pt was climbing the stairs, felt increasingly lightheaded and
chest discomfort (but not pain) and called for her husband. She
was lowered to the floor by her husband and had no head strike
or
injury. Per husband, the patient lost consciousness for ___
minutes, did not feel for a pulse but didn't notice her
breathing
so he was concerned that she was having a cardiac arrest and he
started chest compressions. Did compressions for about 45
seconds and started to notice her stomach moving, so he stopped.
She awoke and had non-bloody emesis. When the patient woke up,
felt very nauseous, not confused. EMS was called and brought
her
in.
In the ED:
-VS: 97 124/68 100 20 100RA FGS 254
-Labs: nl CBC, nl coags, BUN/Cr 36/1.7 (b/l Cr 1.1), K 5.8, ALT
45, AST 97
-ECG: sinus tachycardia, rate 101, nl axis, nl R wave
progression, ___, no ST-T wave changes
-CXR: mild pulmonary vascular congestion
-Received: ativan 1mg IV
On arrival to the floor, patient reports that she feels thirsty,
mild chest discomfort from the compressions. No SOB, stable 3
pillow orthopnea, no PND. Reports mild leg swelling. Reports
2.5 lb weight gain over the last day. No dietary indiscretion,
no
medication non-compliance. Has been taking Lasix 20mg every few
days as needed (when weight increased by 2 lbs).
Past Medical History:
Systolic heart failure
Valvular heart disease - severe AS (bicuspid, ___ 0.6, MG 45,
vel 4.2).
Hypertension
IDDM
metastatic breast CA s/p chemo, XRT, mastectomy
GERD
low back pain
OSA
eczema
autonomic neuropathy
vein stripping
seborrheic keratosis
deviated septum
pilonidal cyst
Social History:
___
Family History:
Her father died at age ___ from complications of diabetes. He
had a history of stroke, hypertension, and hyperlipidemia.
Mother is living, age ___ and suffers from hypertension. She has
one brother, two sisters and no children. Two of her siblings
have hypertension, hyperlipidemia and diabetes. There is no
family history notable for early coronary artery disease or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 91/53 97 20 94RA
Admit weight: 158 lbs
Dry weight: 150 lbs
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: SEM, RRR
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, warm
NEURO: A&Ox3, moving all 4 extremities with purpose, CNs grossly
intact
DISCHARGE PHYSICAL EXAM:
VS: 0744 97.5 93/51 81 18 99 RA
Weight: 68.0 (admit wt: 71.9kg)
GENERAL: WDWN. Resting in bed, in NAD. Very pleasant. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8-10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. High pitched systolic
crescendo-decrescendo murmur best heard at the LUSB. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: 3cm linear sinus with minimal surrounding pink erythema in
the midline of the gluteal cleft.
PULSES: Peripheral pulses intact bilaterally.
Pertinent Results:
ADMISSION LABS:
=====================
___ 06:56PM BLOOD WBC-5.4 RBC-3.79* Hgb-11.2 Hct-35.3
MCV-93 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-44.7 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:56PM BLOOD Glucose-290* UreaN-36* Creat-1.7* Na-133
K-5.8* Cl-94* HCO3-23 AnGap-22*
___ 06:56PM BLOOD ALT-45* AST-97* AlkPhos-76 TotBili-0.4
___ 06:56PM BLOOD Albumin-4.0 Calcium-9.4 Phos-4.0 Mg-2.4
INTERIM LABS:
=====================
___ 06:35AM BLOOD WBC-4.7 RBC-3.61* Hgb-10.7* Hct-34.3
MCV-95 MCH-29.6 MCHC-31.2* RDW-13.2 RDWSD-45.7 Plt ___
___ 07:25AM BLOOD WBC-3.2* RBC-3.68* Hgb-10.7* Hct-34.8
MCV-95 MCH-29.1 MCHC-30.7* RDW-13.2 RDWSD-45.7 Plt ___
___ 07:05AM BLOOD WBC-3.3* RBC-3.61* Hgb-10.6* Hct-34.4
MCV-95 MCH-29.4 MCHC-30.8* RDW-13.2 RDWSD-45.7 Plt ___
___ 06:35AM BLOOD WBC-3.8* RBC-3.72* Hgb-11.0* Hct-35.5
MCV-95 MCH-29.6 MCHC-31.0* RDW-13.4 RDWSD-46.9* Plt ___
___ 05:20AM BLOOD WBC-6.6# RBC-3.86* Hgb-11.4 Hct-36.8
MCV-95 MCH-29.5 MCHC-31.0* RDW-13.6 RDWSD-47.2* Plt ___
___ 07:05AM BLOOD Neuts-56.3 ___ Monos-11.2
Eos-8.8* Baso-0.9 Im ___ AbsNeut-1.85 AbsLymp-0.74*
AbsMono-0.37 AbsEos-0.29 AbsBaso-0.03
___ 07:05AM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 05:20AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-193* UreaN-35* Creat-1.4* Na-137
K-4.1 Cl-96 HCO3-27 AnGap-18
___ 07:25AM BLOOD Glucose-117* UreaN-23* Creat-1.0 Na-142
K-4.6 Cl-102 HCO3-30 AnGap-15
___ 07:05AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
___ 06:35AM BLOOD Glucose-153* UreaN-18 Creat-1.0 Na-142
K-4.6 Cl-103 HCO3-30 AnGap-14
___ 05:20AM BLOOD Glucose-115* UreaN-18 Creat-1.1 Na-142
K-4.5 Cl-101 HCO3-30 AnGap-16
___ 06:35AM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD proBNP-3861*
___ 06:35AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
___ 07:25AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
___ 07:05AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
___ 06:35AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1
___ 05:20AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.1
DISCHARGE LABS:
=====================
___ 05:22AM BLOOD WBC-4.2 RBC-3.87* Hgb-11.6 Hct-36.8
MCV-95 MCH-30.0 MCHC-31.5* RDW-13.7 RDWSD-47.3* Plt ___
___ 05:22AM BLOOD Glucose-144* UreaN-18 Creat-1.0 Na-140
K-3.8 Cl-100 HCO3-30 AnGap-14
MICROBIOLOGY:
=====================
None.
RADIOGRAPHIC STUDIES:
=====================
CHEST XRAY ___:
IMPRESSION:
Possible minimal improvement in previously seen vascular
plethora. Mild prominence of markings in the right suprahilar
region is similar to prior.
Otherwise doubt significant interval change. No pneumothorax,
appreciable left pleural effusion, or displaced rib fracture
detected. No free air seen beneath the diaphragms.
CT head non-con ___:
IMPRESSION: Limited by motion degradation. Within these
limitations, there is no acute intracranial abnormality.
CXR ___: IMPRESSION: Mild pulmonary vascular congestion. No
subdiaphragmatic free air.
Cardiovascular Studies:
+ Echocardiogram ___: The left atrium is normal in size.
The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate to severe global left
ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are severely
thickened/deformed. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Tricuspid valve prolapse is
present. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Compared with the prior study
(images reviewed) of ___, aortic stenosis is now frankly
severe; left ventricular ejection fraction is reduced.
+ Echocardiogram ___ at ___, Mildly dilated
LV(5.7
cm) with moderate to severe global hypokinesis, LVEF 30%,
increased LV filling pressure. Borderline normal RV function,
severe aortic stenosis ___ 0.7 cm2, mean gradient 33 mmHg),
1+MR, 1+TR indeterminant PA pressure.
+ Echocardiogram ___, LVEF 55%, mildly dilated aortic
root, mild AS (aortic valve area 1.2 cm, mean gradient 15 mmHg),
indeterminate pulmonary artery systolic pressure, slightly
higher
transaortic valvular gradients versus prior.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Atorvastatin 10 mg PO QPM
3. Cyclobenzaprine 10 mg PO TID:PRN muscle cramps
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Fulvestrant 250 mg IM 1 INJECTION MONTHLY
6. Gabapentin 900 mg PO TID
7. Furosemide 20 mg PO DAILY
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using novolog Insulin
9. Lisinopril 5 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Gabapentin 900 mg PO BID
3. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.55 units/hr
Basal rate maximum: 0.55 units/hr
Bolus minimum: 0.3 units
Bolus maximum: 10 units
Target glucose: ___
Fingersticks: QAC and HS
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Cyclobenzaprine 10 mg PO TID:PRN muscle cramps
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Fulvestrant 250 mg IM 1 INJECTION MONTHLY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Vitamin D 4000 UNIT PO DAILY
12. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until your doctor tells you to do so
13. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until your doctor tells you to do so
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY:
- Heart failure with reduced ejection fraction
- Severe aortic stenosis
SECONDARY:
- Type 1 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chest pain, vomiting// ? acute process
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest CT ___ and chest radiograph ___
FINDINGS:
Heart size remains mildly enlarged. The mediastinal and hilar contours are
unchanged. Pulmonary vasculature is minimally engorged. Previously noted
increased interstitial opacities in the lung bases appear improved. Linear
opacities within the right midlung field likely reflect areas of scarring and
fibrosis. No focal consolidation, pleural effusion, or pneumothorax is
present. Clips project over both axillary regions. No subdiaphragmatic free
air is present.
IMPRESSION:
Mild pulmonary vascular congestion. No subdiaphragmatic free air.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: ___ year old woman presenting with syncope. Working up for
cardiac cause, however pt did report L arm numbness and with pt's hx of
metastatic breast cancer would like to rule out neurologic/intracranial
cause.// eval for acute intracranial process.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain
windows.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.1 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: MRI head ___.
FINDINGS:
Limited by patient motion. 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. There is mucosal thickening of the bilateral ethmoid
air cells. Remaining paranasal sinuses clear. Mastoid air cells and middle
ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
Limited by motion degradation. Within these limitations, there is no acute
intracranial abnormality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe AS and systolic HF.// pt has upper
L chest wall pain on inspiration. wanted to r/o ptx/ rib fx (received chest
compressions prior to arrival)
TECHNIQUE: Chest, single AP portable view.
COMPARISON: Chest x-ray from ___
FINDINGS:
Compared with ___, I doubt significant interval change.
Cardiomediastinal silhouette is unchanged. Upper zone redistribution may be
slightly improved. Mild prominence of markings in the right suprahilar region
is grossly unchanged. No other evidence of CHF. No focal infiltrate.
Minimal blunting of both costophrenic angles is probably unchanged. No
pneumothorax is identified. No displaced rib fracture is detected. Clips
noted over both axilla, similar to prior. No free air detected beneath the
diaphragm.
IMPRESSION:
Possible minimal improvement in previously seen vascular plethora. Mild
prominence of markings in the right suprahilar region is similar to prior.
Otherwise doubt significant interval change. No pneumothorax, appreciable
left pleural effusion, or displaced rib fracture detected. No free air seen
beneath the diaphragms.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ woman with severe aortic stenosis. Evaluate the
degree of ascending aortic calcification.
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous 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.
Evaluation of solid organs, soft tissues, and vessels is limited without the
use of intravenous contrast.
DOSE: Total DLP (Body) = 200 mGy-cm.
COMPARISON: CTA chest dated ___.
FINDINGS:
The ascending aorta is top-normal in caliber measuring 3.7 cm with mild
intimal faint calcifications. The remaining thoracic aorta is normal in
caliber. Aortic valve calcifications are extensive. Coronary artery
calcifications are difficult to evaluate given motion artifact but may be
mild. Trace pericardial fluid may be physiologic.
No axillary lymphadenopathy. Surgical clips in bilateral axilla are from
management of breast cancer. Enlarged mediastinal lymph nodes particularly in
the lower right paratracheal station and subcarinal stations persist but are
smaller compared to the prior exam, now measuring up to 12-13 mm in short axis
in the subcarinal station. Evaluation for hilar lymphadenopathy is limited
without intravenous contrast but appears less full compared to prior exam.
No new or growing pulmonary nodules. Post-treatment changes in the right
chest wall and pleura are stable. Linear parenchymal right lung scarring and
atelectasis are unchanged. Bulkly atelectasis in the left lower lobe above
the diaphragm and lingula persist, slightly worse from the prior exam,
including a new region in the left lower lobe (series 302, image 131). A left
pleural effusion is small, decreased from prior. Edema has resolved. The
airways are patent to at least the subsegmental level. No pneumothorax.
The thyroid is normal in size without evidence of focal mass.
Multilevel degenerative changes thoracic spine are mild-to-moderate. No
evidence of an acute fracture.
The patient has had right mastectomy with postsurgical change in the chest
wall, similar the prior exam.
This exam is not dedicated for imaging of the upper abdomen. Within this
limitation: The imaged upper abdomen is unremarkable.
IMPRESSION:
1. 3.7 cm ascending thoracic aorta with circumferential faint intimal
calcification.
2. Extensive aortic valve calcification.
3. No new or growing pulmonary nodules.
4. Interval increase in left lower lobe and lingula atelectasis.
5. Interval resolution of pulmonary edema. Persistent small left pleural
effusion.
6. Post-treatment changes in the thorax from breast cancer, unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse, Nonrheumatic aortic (valve) stenosis
temperature: 97.0
heartrate: 102.0
resprate: 18.0
o2sat: 100.0
sbp: 86.0
dbp: 65.0
level of pain: 6
level of acuity: 1.0 | ___ w/ severe AS (bicuspid, ___ 0.6, MG 45, vel 4.2), HFrEF (EF
30%), HTN, HLD, IDDM, OSA, metastatic breast CA admitted
following syncopal event, concerning for cardiogenic syncope ___
valvular disease. A new TTE was obtained showing:
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *71 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Left Ventricle - Ejection Fraction: 30% >= 55%
Based upon these results, it was felt that her syncope was
secondary to exertion, HFrEF, and severe aortic valve stenosis.
Work up was begun for a valve repair. She had a coronary
angiogram on ___ which revealed clean coronaries. ___ evaluated
her and recommended home with home ___, and 24 hour care with her
family to ensure to further falls until she has her valve
replacement.
Throughout the admission, the pt had no further syncopal or near
syncopal events. Her systolic BPs were in the ___
throughout her admission.
ACTIVE ISSUES
================
# Aortic stenosis
# Syncope
Syncope most concerning for cardiogenic syncope secondary to
severe AS. Although she does have factors that contribute to
autonomic dysfunction, including type 1 diabetes and a remote
history of autonomic dysfunction/low BPs in her ___, the severe
AS is the most likely cause. ___ deemed the case high risk.
Structural heart team following pt and will bring her back in
for planned TAVR.
# Systolic heart failure (LVEF 30%)
She does not appear overloaded (mild pulmonary vascular
congestion on CXR, and increased from dry weight but no JVD,
lower extremity edema, or rales). Etiology for her heart failure
is most likely rapid and severe progression of her AS. Started
pt on digoxin.
CHRONIC ISSUES:
================
# CKD
Baseline Cr 1.1. Cr 1.7 on admit, Cr 1.0 today ___ day of DC.
Etiology likely diabetes + cardiorenal.
- trend BUN/Cr
- hold lisinopril for now given soft BPs
# IDDM: insulin pump, ___ consult, patient competent to
manage pump
# Pilonidal cyst: currently being treated as a "pressure ulcer"
but morphologic appearance is consistent with pilonidal cyst.
Has history of pilonidal in her ___, was surgically excised.
Does not appear infected and is not draining. Pt can follow up
in her wound care clinic but also has appt with surgery for
eval.
# OSA: cont home CPAP
# Neuropathy: continue home gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic left salpingo-oophorectomy, aspiration of
left ovarian cyst
___ VAC change
___ skin graft, LLE->abd
___ washout, skin graft RLE->central abd, trach change
___ washout, abthera placement, tracheostomy
___ washout, VAC placement
___ washout, VAC placement
___ washout, VAC placement
___ washout, ___ patch tightening
___ washout, ___ patch tightening, temp dressing
___ exploration, drainage of inter-loop/LUQ abscesses
___ ___ patch placement, abthera
___ ex lap, washout, upper endoscopy
___ ex lap, repair of small bowel injury
___: Laparoscopic left salpingo-oophorectomy, aspiration of
left ovarian cyst
History of Present Illness:
Ms ___ is a ___ female with a history of PCOS who
recently presented to the emergency department with left lower
quadrant pain found to have a left ovarian cyst with torsion.
She underwent laparoscopic left salpingo-oophorectomy with the
OB/GYN service on ___. She was discharged postop ___ stable
condition, however she returned to emergency department shortly
thereafter with worsening postoperative abdominal pain. She had
a sudden onset of suprapubic pain. At the time, no nausea,
vomiting, diarrhea, constipation, dysuria, chest pain, shortness
of breath, fevers, chills, night sweats. ___ the emergency
department her exam noted diffuse abdominal tenderness with
peritoneal signs and a stable hematocrit. CT scan initially
showed a small-to-moderate amount of fluid ___ the pelvis, and
she
was admitted to the OB/GYN service for workup and pain control.
Over the course of her hospital stay, she is continued to have
diffuse abdominal pain, intermittent nausea, and has most
recently developed worsening tachycardia, tachypnea, and
hypotension ___ the ___. Yesterday she had a large bowel
movement which precipitated a moderate increase ___ pain. No
diarrhea, constipation, hematochezia, melena. Intermittently
having nausea still, but no vomiting. Deep breathing limited by
pain. Concern for possible pulmonary embolism the primary team
prompted a CTA of the chest as well as a CT of the abdomen and
pelvis this morning, which showed a moderate amount of free
fluid
___ the pelvis, as well as a large fluid collection ___ the
posterior cul-de-sac. Lactate was checked this morning and
found
to be 6.0. Due to this clinical picture ___ conjunction with her
laboratory and imaging findings, ACS was consulted for
evaluation
and possible surgical management of her deteriorating condition.
Past Medical History:
PMH:
- PCOS
- HLD
PSH:
-Laparoscopic left salpingo-oophorectomy, aspiration of
hemorrhagic left ovarian cyst with possible torsion
-Carpal tunnel release
Social History:
___
Family History:
grandmother with ovarian cancer ___ her ___. otherwise, denies
bleeding/clotting disorders, gyn/GI malignancies, breast cancer
Physical Exam:
Upon consultation:
Vitals: 97.9 | 97.9 | 131 (130s-140s) | 90/63 | 20 | 95 RA
GEN: A&Ox3, NAD, uncomfortable
HEENT: No scleral icterus, mucus membranes dry
CV: Tachycardic, regular, No M/G/R
PULM: Tachypneic, clear to auscultation b/l, No W/R/R
ABD: Distended abdomen, diffusely tender, worst ___ RLQ with
rebound tenderness ___ RLQ and LLQ, tenderness on bed jolt, dull
to percussion over lower abdomen, moderate tympany over upper
abdomen. Surgical sites closed and well healing with no e/i/f.
Ext: No ___ edema, feet slightly cool, no mottling of skin
Upon discharge: ___
vital signs: 98.2, hr=100, bp=124/82, rr=18, 98% room air
General: NAD
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: soft, open wound with adaptic dressing and moist kerlex
around perimeter, fibrinous tissue left lateral aspect of wound
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___:
1. Re-demonstration of a large 8.7 x 5.6 x 6.8 cm left adnexal
cystic lesion compatible with endometrioma. The midline
location and mildly edematous ovary draped around the cystic
lesion is suspicious for torsion.
2. Small amount of free pelvic fluid.
CTA chest and CT abdomen ___
1. Findings of small-bowel ileus with probable early mechanical
small bowel obstruction related to distal ileal loops ileitis
secondary to the inflammatory changes within the pelvis. NG
tube placement would be beneficial to decompress proximal small
bowel loops.
2. Pneumoperitoneum, expected postsurgically.
3. Progression of moderate amount of free intraperitoneal fluid,
some of which appear rim enhancing within the pelvis concerning
for an peritonitis within the pelvis. Bowel injury cannot be
excluded given lack of oral contrast opacification. No biliary
leak.
4. No acute pulmonary emboli or acute aortic syndrome.
CT chest ___
1. Small left pleural effusion.
2. Bibasilar and right middle lobe opacities most consistent
with atelectasis. Clinical correlation for superimposed
infection is recommended.
CT abd/pelvis ___
1. Small volume ascites with numerous organizing collections,
largest measuring 8.2 cm within the dependent portion of the
pelvis.
2. Findings consistent with peritonitis.
CT ___ ___
1. successful CT-guided placement of an ___ pigtail
catheter into the pelvic collection. Samples were sent for
microbiology evaluation.
___: CXR:
The tip of the new left PICC line projects approximately 3 cm
beyond the
cavoatrial junction. No pneumothorax. Unchanged
cardiopulmonary findings.
CT A/P ___
1. Redemonstration of peritonitis. Decreased size of pelvic
abscess with posterior approach drainage catheter terminating
outside of this collection.
2. Interval decrease ___ size ___ multiple abdominal collections,
as detailed above.
3. New perigastric non organized pocket of fluid, nonspecific
and stable although more organized right perihepatic collection.
CT chest ___
1. Left pleural effusion with adjacent atelectasis has mildly
improved ___ comparison to ___.
2. Stable right basilar opacity and interval improvement of
right middle lobe opacity, most consistent with atelectasis.
Stable small right pleural effusion.
CT ___ ___
Successful CT-guided placement of ___ pigtail catheter
into the pelvic collection. Samples were sent for microbiology
evaluation.
CT abd/pelvis ___:
1. Decrease ___ size of multiple fluid collections ___ the abdomen
and pelvis, the largest is a pelvic abscess which previously
measured 7.1 x 3.7 cm and now measures 6.5 x 2.4 cm.
2. No extraluminal contrast or free air is seen to suggest a
leak.
3. Improvement ___ edema and mesenteric fat stranding ___ the
anterior abdomen with decrease ___ mildly prominent small bowel
loops with mild wall thickening. Findings likely represent
improving peritonitis.
4. Bilateral pleural effusions with associated atelectasis.
___ 6:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
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
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 1:45 pm PERITONEAL FLUID PERITONEAL FLUID.
Fluid should not be sent ___ swab transport media. Submit
fluids ___ a
capped syringe (no needle), red top tube, or sterile cup.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
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, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE
NEGATIVE.
___ 9:54 am PERITONEAL FLUID Site: PELVIS
PELVIC DRAIN S/P ___ ___ ADVANCEMENT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
Reported to and read back by ___ ( ___ @
1339 ON
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
test result performed by Sensititre.
CLINDAMYCIN MIC <= .12 MCG/ML.
CEFTRIAXONE test result performed by Etest.
AMPICILLIN Susceptibility testing requested by ___
___
___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------<=0.12 S <=2 S
CEFTRIAXONE----------- 1 S
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S 2 S
VANCOMYCIN------------ <=1 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___: CXR:
Compared to the examination from 2 days prior, there is been a
replacement of the upper enteric tube with Dobhoff tube tip
terminating at least the level of the mid to distal gastric body
with tip outside of field-of-view. Otherwise there is little
interval change. Lung volumes remain very low with probable
small effusions and bibasilar atelectasis. Cardio-mediastinal
silhouette is unchanged. Upper lung zones are clear. There is
no pneumothorax. Left PICC is unchanged.
___: CT abd. and pelvis:
1. Decrease ___ size of multiple fluid collections ___ the abdomen
and pelvis, the largest is a pelvic abscess which previously
measured 7.1 x 3.7 cm and now measures 6.5 x 2.4 cm.
2. No extra-luminal contrast or free air is seen to suggest a
leak.
3. Improvement ___ edema and mesenteric fat stranding ___ the
anterior abdomen with decrease ___ mildly prominent small bowel
loops with mild wall thickening.
Findings likely represent improving peritonitis.
4. Bilateral pleural effusions with associated atelectasis.
___ 9:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
___ 06:09AM BLOOD WBC-5.0 RBC-3.20* Hgb-8.8* Hct-29.2*
MCV-91 MCH-27.5 MCHC-30.1* RDW-16.8* RDWSD-56.3* Plt ___
___ 05:19AM BLOOD WBC-5.8 RBC-3.59* Hgb-9.8* Hct-32.5*
MCV-91 MCH-27.3 MCHC-30.2* RDW-16.9* RDWSD-56.6* Plt ___
___ 05:30AM BLOOD WBC-6.7 RBC-3.56* Hgb-9.7* Hct-32.1*
MCV-90 MCH-27.2 MCHC-30.2* RDW-17.1* RDWSD-56.5* Plt ___
___ 03:07AM BLOOD WBC-6.4 RBC-4.60 Hgb-12.3 Hct-38.8 MCV-84
MCH-26.7 MCHC-31.7* RDW-13.3 RDWSD-41.0 Plt ___
___ 09:35PM BLOOD Neuts-73* Bands-2 Lymphs-13* Monos-10
Eos-0 Baso-1 ___ Metas-1* Myelos-0 AbsNeut-8.63*
AbsLymp-1.50 AbsMono-1.15* AbsEos-0.00* AbsBaso-0.12*
___ 06:09AM BLOOD Plt ___
___ 06:09AM BLOOD Glucose-122* UreaN-17 Creat-0.3* Na-140
K-4.5 Cl-101 HCO3-25 AnGap-14
___ 05:19AM BLOOD Glucose-142* UreaN-15 Creat-0.3* Na-140
K-4.7 Cl-97 HCO3-25 AnGap-18*
___ 05:30AM BLOOD Glucose-148* UreaN-16 Creat-0.3* Na-139
K-4.4 Cl-96 HCO3-26 AnGap-17___ 03:07AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-143
K-4.5 Cl-107 HCO3-22 AnGap-14
___ 06:09AM BLOOD ALT-21 AST-34 AlkPhos-185* TotBili-0.5
___ 02:16AM BLOOD ALT-20 AST-38 AlkPhos-356* TotBili-1.8*
___ 06:34PM BLOOD ALT-22 AST-48*
___ 02:16AM BLOOD Triglyc-452*
___ 03:26PM BLOOD Type-ART pO2-104 pCO2-38 pH-7.48*
calTCO2-29 Base XS-4
___ 04:07AM BLOOD freeCa-1.10*
___ 07:05PM BLOOD freeCa-1.08*
Medications on Admission:
Medications - Prescription
ATORVASTATIN - atorvastatin 10 mg tablet. 1 tablet(s) by mouth
once a day - (Prescribed by Other Provider)
HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by
mouth
every 4 hours as needed for pain do not drive while taking, use
with stool softener
IBUPROFEN - ibuprofen 600 mg tablet. 1 tablet(s) by mouth every
6
hours as needed for pain take with food
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. ___ tablet(s) by
mouth every 6 hours as needed for pain do not exceed 4000 mg ___
24 hours
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN thick secretions
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Calcium Carbonate 500 mg PO QID:PRN nausea
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID:PRN
mouthwash
6. CloNIDine 0.05 mg PO BID
please continue to wean this medication off
7. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
8. FLUoxetine 20 mg PO DAILY
9. Heparin 5000 UNIT SC BID
may d/c after patient ambulatory
10. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
please take with food
11. LORazepam 0.5-2 mg PO Q6H:PRN anxiety
12. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: dc other
13. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*30 Packet Refills:*2
14. Senna 8.6 mg PO BID:PRN constipation
15. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
peritonitis
small bowel injury
septic shock
respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent ( requires assistance
with ambulation related to de-conditioning)
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated// interval changes
TECHNIQUE: 2 frontal views of the chest
COMPARISON: ___
FINDINGS:
Bibasilar hazy opacities, more notably on the left, which could reflect
subsegmental atelectasis with possible underlying left effusion, stable.
Extremely low lung volumes. Tubes and lines are stable.
Mild cardiomegaly stable.
No pneumothorax.
IMPRESSION:
No significant change
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with effusion// interval change
TECHNIQUE: Chest, single AP view
COMPARISON: Chest x-ray from ___ at 06:00
FINDINGS:
An ET tube is present, tip approximately 3.0 cm above the carina. An NG tube
is present, tip and side-port extending beneath diaphragm, with tip extending
off film. Right IJ central line tip overlies the right atrium and courses to
the left suggestive of left-sided volume loss. No pneumothorax detected.
Inspiratory volumes are quite low. There does appear to be some leftward
shift of the cardiomediastinal silhouette, even allowing for slight patient
rotation. The heart is not enlarged.
Diffuse vascular plethora is likely accentuated by low lung volumes. There is
increased retrocardiac density consistent with left lower lobe collapse and/or
consolidation. The more hazy opacity previously seen in the upper zones has
improved, particularly in the left mid zone. No gross effusion identified,
though small effusions might not be apparent.
IMPRESSION:
Low inspiratory volumes. Probable left-sided volume loss. Slight interval
improvement in hazy opacities previously seen in the left mid and zones.
Otherwise, doubt gross change.
Right IJ line tip overlies the right atrium.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with rotated CXR on AM rounds// achieve
acceptable cxr
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-ray from ___ at 06:15
FINDINGS:
ET tube tip lies approximately 2.9 cm above the carina. NG tube and side-port
extend beneath the diaphragm and overlie the upper stomach. Right IJ central
line overlies the right atrium and courses slightly to the left, similar to
the prior film, suggesting possible slight left-sided volume loss. No
pneumothorax detected.
As before, there are quite low inspiratory volumes, with bibasilar
atelectasis. Left lower lobe consolidation would be difficult to exclude in
this setting. Small left effusion is likely present, better delineated on the
current film. Prominence of vascular markings is likely accentuated by low
lung volumes.
Cardiomediastinal silhouette is grossly unchanged.
IMPRESSION:
No definite change compared with earlier the same day. Possible slight
left-sided volume loss.
Right IJ central line again overlies the lower right atrium. Clinical
correlation regarding possible repositioning is requested.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo intubated in ICU// assess lines tubes and lungs
IMPRESSION:
In comparison with the study of ___, there again are extremely low lung
volumes that accentuate the enlargement of the cardiac silhouette. Again
there are layering pleural effusions with compressive basilar atelectasis,
more prominent on the left. Pulmonary vascularity is difficult to assess,
though there is only mild vascular congestion.
Monitoring and support devices are stable and in satisfactory position.
Radiology Report
EXAMINATION: CT abdomen/pelvis with contrast.
INDICATION: ___ year old woman with intraop bowel injury s/p repair, currently
intubated. Concern for intraadominal fluid collection. Assess for Pleural
effusion, intraabdominal collections, please use IV CONTRAST ONLY
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 69.7 cm; CTDIvol = 20.1 mGy (Body) DLP =
1,403.0 mGy-cm.
2) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 25.1 mGy (Body) DLP =
12.6 mGy-cm.
Total DLP (Body) = 1,416 mGy-cm.
COMPARISON: Outside CT abdomen ___.
FINDINGS:
LOWER CHEST: Please refer to dedicated CT chest for further details.
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. Mild gallbladder wall edema is likely
reactive. The gallbladder is nondistended. No gallstones identified.
(02:49). Small volume ascites with numerous areas that demonstrate partial
enhancing walls and are partially organized, largest of which measures
approximately 6 x 3.4 cm along the gastrohepatic region (02:50). No discrete
abdominal collection that is fully organized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. Peripancreatic free fluid is
noted.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. Perisplenic free fluid noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Stable 0.5 cm left lower pole renal hypodensity is incompletely
characterized and most consistent with a renal cyst. (2:73). The kidneys
otherwise are of normal and symmetric size with normal nephrogram. There is
no evidence of worrisome renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: An enteric feeding tube courses midline with tip in stomach.
Stomach is decompressed. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal. Diffuse peritoneal enhancement noted.
PELVIS: The urinary bladder is decompressed with a Foley catheter and expected
locules of gas. Distal ureters unremarkable. Moderate amount of
nonhemorrhagic fluid within the pelvis has increased since prior examination
now measuring 4.6 x 8.2 cm with new peripheral rim enhancement consistent with
ongoing organization (2:102). Of note the right ovary is located within this
collection.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Multiple subcentimeter retroperitoneal lymph nodes are again
noted, largest measures up to 0.9 cm within the left periaortic region (2:67),
and has slightly increased since prior examination, likely reactive. No
mesenteric lymph node enlargement. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Patient is status post midline incision with evisceration and
surgical staples along the right lateral incision site. The abdominal and
pelvic wall is otherwise within normal limits.
IMPRESSION:
1. Small volume ascites with numerous organizing collections, largest
measuring 8.2 cm within the dependent portion of the pelvis.
2. Findings consistent with peritonitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 6:54 pm, 15 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with intraoperative bowel injury status post
repair, currently intubated. Assess for intra-abdominal fluid collection.
TECHNIQUE: Axial helical MDCT images were obtained through the chest.
Coronal and sagittal reformats were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 69.7 cm; CTDIvol = 20.1 mGy (Body) DLP =
1,403.0 mGy-cm.
2) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 25.1 mGy (Body) DLP =
12.6 mGy-cm.
Total DLP (Body) = 1,416 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CTA chest ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Limited view of the thyroid is
unremarkable. No supraclavicular or axillary lymph node enlargement. The
chest wall is unremarkable.
UPPER ABDOMEN: Please refer to same-day CT abdomen/pelvis for details.
MEDIASTINUM: Mediastinal lymph nodes are nonenlarged. No mediastinal
hematoma.
HILA: Hilar lymph nodes are nonenlarged.
HEART and PERICARDIUM: Heart is normal in size. No pericardial effusion.
PLEURA: Small left non hemorrhagic pleural effusion. No right pleural
effusion. No pneumothorax.
LUNG:
1. PARENCHYMA: Bibasilar and right middle lobe opacities are noted. No
pulmonary nodule.
2. AIRWAYS: An endotracheal tube terminates 2 cm above the level of the
carina. The airways are otherwise unremarkable. No bronchiectasis. No
bronchial wall thickening.
3. VESSELS: Limited assessment for pulmonary embolism giving timing of
contrast bolus however no central pulmonary embolism identified. Main
pulmonary artery is normal in caliber. The thoracic aorta is normal in
caliber without aneurysmal dilatation. No dissection. No intramural
hematoma.
CHEST CAGE: No focal lytic or blastic lesions worrisome for malignancy. No
acute fracture.
IMPRESSION:
1. Small left pleural effusion.
2. Bibasilar and right middle lobe opacities most consistent with
atelectasis. Clinical correlation for superimposed infection is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubated with abdominal abscess// assess
tld lungs
IMPRESSION:
In comparison with the study ___, the monitoring and support devices are
unchanged. Again there is extremely low lung volumes that accentuates the
enlargement the cardiac silhouette. The layering pleural effusions and degree
of pulmonary edema are unchanged.
Radiology Report
EXAMINATION: CT-GUIDED PELVIC COLLECTION DRAINAGE
INDICATION: ___ year old woman history of PCOS s/p oopherectomy for ovarian
cyst subsequently found to have SB perf and repair with intraabdominal
collections with largest in the pelvis// Drainage of intraabdominal fluid
COMPARISON: Recent CT abdomen and pelvis from ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending
radiologist. Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a left lateral decubitus position on the CT scan
table. Limited preprocedure CT scan was performed to localize the collection.
Based on the CT findings an appropriate skin entry site for the drain
placement was chosen. The site was marked. Local anesthesia was administered
with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection from a left sided approach, however a catheter
could not be advanced over the wire. A right sided approach was then chosen
and demonstrated the wire coiling in a small pocket of fluid confirming a
septated collection. We then returnd to the left-sided approach where the
wire had coiled in a larger part of 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 serial dilation and by placement of ___ Exodus pigtail catheter into
the collection. The plastic stiffener and the wire were removed. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via CT fluoroscopy.
Approximately 45 cc of serosanguinous fluid was aspirated with a sample sent
for microbiology evaluation. The catheter was secured by a StatLock. The
catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.6 s, 32.4 cm; CTDIvol = 18.9 mGy (Body) DLP =
588.2 mGy-cm.
2) Stationary Acquisition 0.4 s, 1.4 cm; CTDIvol = 3.8 mGy (Body) DLP = 5.4
mGy-cm.
3) Stationary Acquisition 0.7 s, 1.4 cm; CTDIvol = 13.6 mGy (Body) DLP =
19.6 mGy-cm.
4) Stationary Acquisition 24.2 s, 1.4 cm; CTDIvol = 583.5 mGy (Body) DLP =
840.3 mGy-cm.
Total DLP (Body) = 1,467 mGy-cm.
SEDATION: Sedation is administered by the ICU nurse.
FINDINGS:
Noncontrast CT of the pelvis re-demonstrates the fluid collection in the
pelvis.
IMPRESSION:
1. successful CT-guided placement of an ___ pigtail catheter into the
pelvic collection. Samples were sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with intubated with abdominal abscess currently
intubated// ? Interval changes
TECHNIQUE: Portable supine radiograph of the chest.
COMPARISON: Radiograph from ___. CT chest from ___.
FINDINGS:
The endotracheal tube terminates approximately 1.8 cm above the carina. Right
IJ is unchanged in position compared to the prior exam. Lung volumes are low
which accentuates the cardiomediastinal silhouette. Mild bibasilar
atelectasis is unchanged compared to the prior exam. Small bilateral pleural
effusions, left greater than right are unchanged. There is no evidence of
pneumothorax.
IMPRESSION:
Overall, stable appearance of hypoinflated lungs and adjacent atelectasis.
Stable small bilateral pleural effusions, left greater than right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p abdominal washout// Assess for T/L/D, and
interval changes Assess for T/L/D, and interval changes
IMPRESSION:
ET tube tip is 3.5 cm above the carinal. NG tube tip is in the stomach.
Right internal jugular line tip is at the cavoatrial junction.
Lung volumes remain low. Bibasal atelectasis and mild vascular conjunction is
similar to previous examination. Bilateral pleural effusion is most likely
present, left more than right, small to moderate.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated// interval change interval
change
IMPRESSION:
ET tube tip is 3.5 cm above the carinal. NG tube passes below the diaphragm
terminating in the stomach. Right internal jugular line tip is at the
cavoatrial junction. Lung volumes remain low. Pulmonary edema has progressed
in the interim, severe. Left retrocardiac consolidation has increased.
Radiology Report
INDICATION: ___ year old woman with post OR desat increased peak pressures//
assess for pneumothorax
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the mid thoracic trachea. A
feeding tube extends below the level of the diaphragm but beyond the field of
view of this radiograph. The tip of a right internal jugular central venous
catheter projects over the right atrium.
Low bilateral lung volumes. Unchanged pulmonary edema and atelectasis. A
small left pleural effusion is also noted. No discrete pneumothorax is
identified.
IMPRESSION:
No discrete pneumothorax is identified. Otherwise unchanged cardiopulmonary
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation in TSICU// assess tubes lines
drains lungs
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged. Again there are low lung volumes that accentuate
the transverse diameter of the heart. Mild elevation of pulmonary venous
pressure with basilar atelectatic changes and probable small effusions.
Elevation of the right hemidiaphragmatic contour is again seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with continued intubation s/p bowel perf// eval
for interval change eval for interval change
IMPRESSION:
ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Right
internal jugular line tip is in the proximal right atrium.
Heart size and mediastinum are unchanged. There is pulmonary edema which is
moderate to severe associated with bilateral pleural effusions, slightly
progressed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation// interval change interval
change
IMPRESSION:
Compared to chest radiographs ___ through ___ at 06:00.
Progressive opacification of the left hemithorax is no doubt due in part to
increasing pleural effusion, but concurrent consolidation is of concern. On
the right, previous perihilar consolidation has improved but there is still at
least a small right pleural effusion and basilar atelectasis. Heart size
top-normal is exaggerated by low lung volumes. No pneumothorax.
ET tube is in standard placement. Right internal jugular line ends in the
right atrium. Transesophageal drainage tube passes into the stomach and out
of view.
Radiology Report
INDICATION: ___ year old woman s/p ex-lap bowel repair w/ multiple washouts.
No bowel movement since admission. Unable to tolerate tube feed. Study
performed to evaluate for obstruction, dilated bowels, stool burden.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
Air is seen within the transverse colon. Otherwise there is a paucity of
bowel gas, which may be due to intra-abdominal fluid collections. No
abnormally dilated large or small bowel is seen. There is no evidence of
obstruction.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. An NG tube is seen with its tip within the expected position of the
stomach. Pigtail catheter noted within the pelvis. Wound collection system
is noted. Staples overlying the right lower abdomen.
IMPRESSION:
Paucity of bowel gas, which may be due to intra-abdominal fluid collections.
No abnormally dilated large or small bowel is seen. There is no evidence of
obstruction.
Radiology Report
EXAMINATION: Portable semi-erect AP chest radiograph
INDICATION: ___ year old woman with open abdomen and washout continue to be
intubated. Assess T/L/D, Interval changes
TECHNIQUE: Chest AP
COMPARISON: Prior radiograph on ___
FINDINGS:
The endotracheal tube tip terminates approximately 2 cm above the carina and
appears to be coursing towards the right mainstem bronchus; if the neck is not
flexed, recommend adjustment of tube. Orogastric tube descends into the
stomach and out of view.
Compared to the prior radiograph on ___, the lung volumes remain
comparatively low but there has been considerable improvement in the left
hemothorax opacification suggesting improvement in pleural effusions. The
effusion appears small to moderate on the left with resolution on the right.
No apparent focal consolidations. Mediastinal contour is unchanged. No acute
osseous abnormalities.
IMPRESSION:
Endotracheal tube tip approximately 2 cm above the carina coursing towards
right mainstem bronchus; if the neck is not flexed, recommend adjustment of
the tube.
Improving pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:26 pm, 45 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Semi-erect portable AP chest radiograph
INDICATION: ___ year old woman s/p ex-lap, small bowel repair with
intraabdominal collections s/p multiple abdominal washout with abdomen open
and remain intubated// Assess for T/L/D, interval changes
TECHNIQUE: Chest AP
COMPARISON: Chest radiograph on ___
FINDINGS:
The endotracheal tube tip now terminates approximately 3 cm above the carina.
RIJ tip terminates in the right atrium.
Compared to the prior radiograph on ___, there is new, mild
asymmetric pulmonary edema with stable left pleural effusion and improved,
minimal right pleural effusion. No new focal consolidations. The
cardiomediastinal contour is unchanged and size and configuration. Hilar
contour is unchanged.
IMPRESSION:
New mild asymmetric pulmonary edema with stable left pleural effusion and
improved right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubation, getting diuresed// assess
volume status assess volume status
IMPRESSION:
Compared to chest radiographs ___ through ___.
Predominantly left-sided pulmonary consolidation is slowly improving. Whether
this is asymmetric edema or pneumonia is difficult to say. There at least
small bilateral pleural effusions and the heart is moderately enlarged. Dense
consolidation at the base the left lung could be atelectasis in combination
with edema or even pneumonia, and has not improved recently.
No pneumothorax.
Right jugular line ends in the right atrium, nasogastric drainage tube passes
into the stomach and out of view. With the chin down, ET tube tip position,
2.5 cm from the carina is appropriate.
Radiology Report
INDICATION: ___ year old woman with open abdomen s/p washouts, remain
intubated// Assess T/L/D, interval changes
TECHNIQUE: Portable semi-erect radiograph the chest.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The ET tube terminates approximately 2.9 cm above the carina. A nasogastric
tube extends below the diaphragm, with the tip out of view of the stomach. A
left-sided PICC line appears overall similar in position compared to the prior
exam. The tip of the right internal jugular central venous catheter is
unchanged.
Persistently low bilateral lung volumes with mild asymmetric pulmonary
edema/pneumonia is unchanged compared to the prior exam. Small left pleural
effusion is stable. The size and appearance of the cardiomediastinal
silhouette is unchanged. There is no evidence of a pneumothorax.
IMPRESSION:
Overall, stable low lung volumes with bibasilar atelectasis and small left
pleural effusion. ET tube terminates 2.9 cm above the carina.
Radiology Report
INDICATION: ___ year old woman with new PICC// assess picc line placement
Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The tip of the endotracheal tube projects over the mid thoracic trachea. The
tip of the new left PICC line projects over the right atrium, approximately 3
cm beyond the cavoatrial junction. The tip of the right internal jugular
central venous catheter is unchanged. The tip of the feeding tube projects
below the level the diaphragm but beyond the field of view of this radiograph.
There are persistently low bilateral lung volumes with asymmetric pulmonary
edema and/or pneumonia. A layering left pleural effusion is present. No
pneumothorax. The size and appearance of the cardiomediastinal silhouette is
unchanged.
IMPRESSION:
The tip of the new left PICC line projects approximately 3 cm beyond the
cavoatrial junction. No pneumothorax. Unchanged cardiopulmonary findings.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman s/p abdominal washout and vac placement//
Assess for T/L/D and interval changes
TECHNIQUE: Portable chest x-ray
COMPARISON: Portable chest x-ray from ___ approximately 15 hours
prior.
FINDINGS:
The study is compromised secondary to oblique positioning.
Previous portable chest x-ray from ___ approximately 15 hours
prior. The tip of the endotracheal tube is unchanged in position. The NG tube
extends below the left hemidiaphragm, the tip is not visualized. The tip of
the left PICC is not adequately seen secondary to overlying lines and
technique.
There are low lung volumes with asymmetric pulmonary edema and/or pneumonia.
There is a layering left effusion, not significantly changed. The
cardiomediastinal silhouette is grossly unchanged, difficult to assess given
low volumes and oblique positioning.
IMPRESSION:
The study is compromised secondary to technique and patient positioning.
Endotracheal tubea is in good position. The tip of the PICC is not adequately
visualized.
Heart and lungs essentially unchanged when compared to the prior study from
earlier in the same day.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated// interval change interval
change
IMPRESSION:
Comparison to ___. Decrease in extent and severity of a
pre-existing right pleural effusion, new blunting of the left costophrenic
sinus, likely reflecting a small left pleural effusion. Stable monitoring and
support devices. Stable moderate cardiomegaly at very low lung volumes, mild
fluid overload but no overt pulmonary edema. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with continued intubation// eval for interval
change
TECHNIQUE: Portable AP radiograph the chest.
COMPARISON: Radiograph from ___.
FINDINGS:
Compared to the most recent prior exam, there has been slight interval
improvement of the previously seen pulmonary vascular congestion. A small
left pleural effusion is unchanged compared to the prior exam. Small right
pleural effusion is stable. Mild bibasilar atelectasis is persistent. There
is no evidence of pneumothorax. Right-sided internal jugular line and
right-sided PICC line terminates in the right atrium.
IMPRESSION:
Overall, no significant interval change in the appearance of the chest, with
persistent small bilateral pleural effusions. Slight interval improvement in
the previously seen pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with small bowel perforation s/p repair and
complicated by leak, continue to be intubated// Assess T/L/D, interval changes
IMPRESSION:
In comparison with the study of ___, there again are very low lung
volumes with enlargement of the cardiac silhouette and mild elevation of
pulmonary venous pressure. Retrocardiac opacification with poor definition of
the hemidiaphragms consistent with pleural fluid and volume loss in left lower
lobe. Less prominent changes are seen at the right base.
Monitoring and support devices are essentially unchanged.
Radiology Report
INDICATION: ___ s/p laparoscopic left salpingooophorectomy for ovarian
torsion, with significant continued postoperative nausea and vomitting//
postoperative nausea and vomiting, concerning for ileus
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT scan of the abdomen and pelvis dated ___
FINDINGS:
There are mildly dilated loops of small bowel. Air is seen within the colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Mildly prominent loops of small bowel in the mid abdomen. Air and stool are
seen throughout the colon and these findings likely reflect a postoperative
ileus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with trach// interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged. Continued low lung volumes accentuate the size of
the cardiac silhouette. The left effusion is less prominent, though this
could merely represent a more upright position of the patient.
Radiology Report
INDICATION: ___ year old woman tracheostomy// position of trach
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___
FINDINGS:
A tracheostomy has been placed. The tip of the left PICC is unchanged. The
tip of the right IJ line is unchanged imposition.
There are low lung volumes, compromising evaluation. There is a left pleural
effusion. Atelectatic changes are seen at the right lung base.
IMPRESSION:
The patient is status post tracheostomy placement. Heart and lungs appear
unchanged when compared to a prior study from 14 hours previous.
Radiology Report
EXAMINATION: CT abdomen and pelvis with intravenous contrast.
INDICATION: ___ year old female with abdominal small bowel perf// fluid
collections intra abdominally
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: Total DLP (Body) = 1,262 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
CHEST:
Small bilateral pleural effusions with compressive and subsegmental
atelectasis in the bilateral lower lobes are unchanged.
ABDOMEN AND PELVIS:
There is a pelvic abscess measuring 7.1 x 3.4 cm (2:101), decreased in size
from CT ___, previously measuring 4.6 x 8.2 cm. The pigtail
drainage catheter in the cul-de-sac appears to terminate outside of this
collection along its left lateral edge.
Along the greater curvature of the stomach, there is a fluid collection
measuring 3.5 x 1.9 cm (02:59), decreased in size, previously measuring 3.4 x
6.1 cm. Along the lesser curvature, there is a fluid collection measuring up
to 3.2 cm across maximal diameter (02:56), decreased in size, previously
measuring up to 5.6 cm. ___ fluid collection is unchanged in size
from CT ___.
There is a pocket of non organized fluid inferior to the stomach measuring 2.8
x 4.4 cm (2:66) which is new as compared to CT ___. A ___
pocket of fluid measuring 3.5 cm in maximal diameter (2:62) appears more
well-formed.
An open abdominal wound is again noted. Enteric tube terminates in the
proximal gastric body. The liver, spleen, adrenal glands, and bilateral
kidneys are unchanged and unremarkable. Mildly prominent small bowel loops
with associated air-fluid levels without definite transition point are noted
which could be secondary to peritonitis.
A gain seen is diffuse mesenteric edema. Post left oophorectomy. The fluid
collection in the pelvis abuts the right adnexa. An indwelling Foley catheter
is noted. No change in osseous structures.
IMPRESSION:
1. Redemonstration of peritonitis. Decreased size of pelvic abscess with
posterior approach drainage catheter terminating outside of this collection.
2. Interval decrease in size in multiple abdominal collections, as detailed
above.
3. New perigastric non organized pocket of fluid, nonspecific and stable
although more organized right perihepatic collection.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with abdominal small bowel perforation,
tracheostomy and pleural effusions.
Interval change are effusions?
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 66.7 cm; CTDIvol = 18.7 mGy (Body) DLP =
1,248.3 mGy-cm.
2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 27.9 mGy (Body) DLP =
14.0 mGy-cm.
Total DLP (Body) = 1,262 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Previous studies last CT of the chest dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Tracheostomy tube terminating in
the in the trachea.
There is no supraclavicular or axillary lymphadenopathy.
There is no axillary lymphadenopathy.
Bilateral flank subcutaneous fat stranding-unchanged subcutaneous edema.
UPPER ABDOMEN: Nasogastric tube extending to the stomach.
Upper abdominal organs will be reported in the dedicated concurrent CT of the
abdomen and pelvis accession ___.
MEDIASTINUM: Few measurable lymph nodes not pathologically enlarged in the
mediastinum are unchanged.
New 7 mm lymph node in the AP window, most probably reactive.
No lymphadenopathy in the hila.
HEART and PERICARDIUM: Left PICC line and Right internal jugular line
terminating in the right atrium.
There is no cardiomegaly and no pericardial effusion.
Major vessels are within normal size.
LUNG: Major ways are patent bilaterally.
Bilateral small pleural effusions with adjacent passive atelectasis-the left
pleural effusion has mildly improved in comparison to ___.
There is no evidence of consolidation suspected as pneumonia.
CHEST CAGE: No evidence of bony destructive lesions.
IMPRESSION:
1. Left pleural effusion with adjacent atelectasis has mildly improved in
comparison to ___.
2. Stable right basilar opacity and interval improvement of right middle lobe
opacity, most consistent with atelectasis. Stable small right pleural
effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p trach, open abdomen// Interval changes,
assess T/L/D Interval changes, assess T/L/D
IMPRESSION:
The cavoatrial junction. Heart size and mediastinum are stable. Bi basal
opacities in small pleural effusion are unchanged.
Radiology Report
EXAMINATION: Portable chest radiographs.
INDICATION: ___ year old woman with post-op, new skin graft// t/l/d, pna,
volume status
TECHNIQUE: AP chest x-ray
COMPARISON: Comparison to chest radiographs ___.
FINDINGS:
Low lung volumes bilaterally. Tracheostomy and support lines unchanged from
previous imaging. Slight increase in right-sided small pleural effusion. The
cardiomediastinal silhouette appears stable. No new focal consolidation
identified or evidence of worsening pulmonary congestion, however assessment
is limited due to low lung volumes.
IMPRESSION:
Lower lung volumes with associated atelectasis.
Radiology Report
EXAMINATION: CTA CHEST ABDOMEN AND PELVIS
INDICATION: ___ year old woman ___ s/p lsc left salpingoophorectomy, post op
course complicated by tachycardia to 130's, new oxygen requirement// please
protocol to r/o pulmonary emboli
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
from the thoracic inlet through the abdomen and pelvis following intravenous
contrast administration with split bolus technique. CT PE protocol was
followed for the chest and routine portal venous phase for the abdomen and
pelvis.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 4.9 s, 0.2 cm; CTDIvol = 82.2 mGy (Body) DLP =
16.4 mGy-cm.
3) Spiral Acquisition 2.8 s, 18.1 cm; CTDIvol = 9.8 mGy (Body) DLP = 170.7
mGy-cm.
4) Spiral Acquisition 8.9 s, 57.9 cm; CTDIvol = 13.9 mGy (Body) DLP = 794.4
mGy-cm.
5) Spiral Acquisition 8.9 s, 57.9 cm; CTDIvol = 5.7 mGy (Body) DLP = 324.3
mGy-cm.
Total DLP (Body) = 1,308 mGy-cm.
COMPARISON: CT abdomen pelvis outside institution ___.
FINDINGS:
CHEST:
PULMONARY ARTERIES/AORTA: Normal caliber thoracic aorta. No acute aortic
syndrome. No acute pulmonary emboli.
AIRWAYS: Major airways are clear. No endotracheal or endobronchial lesions.
MEDIASTINUM: No mediastinal or hilar adenopathy. No cardiomegaly. No
pericardial effusion.
LUNGS: New dependent atelectatic changes with partial collapse left lower
lobe.
PLEURA: New trace bilateral pleural effusions.
ABDOMEN:
HEPATOBILIARY: Homogeneous hepatic enhancement. Portal vein is patent.
Contrast opacifies gall bladder lumen related to the recent contrast enhanced
procedure. No intrahepatic or extrahepatic bile ductal dilatation.
PANCREAS: Unremarkable.
SPLEEN: Normal in size.
ADRENALS: Normal adrenals.
URINARY:No hydronephrosis. No nephrolithiasis. Intact ureters. Bladder is
unremarkable. No urinary leak.
GASTROINTESTINAL: Low-density fluid opacifies lumen of distal esophagus.
Stomach appears distended with low density fluid. Upper abdominal small bowel
loops are dilated as well. Transition point appears to be in the lower
abdomen (axial image 72 series 10), where a distal ileal loop demonstrates
mild wall thickening, luminal narrowing and mucosal hyperemia indicative of
acute ileitis likely secondary to inflammatory changes within the pelvis.
There is resultant predominantly paralytic ileus as well as mechanical
small-bowel obstruction related to the inflammatory changes in the pelvis.
Large bowel diverticulosis.
PERITONEUM: Extensive amounts of free intraperitoneal air and free fluid.
Free intraperitoneal air appears unchanged, can be explained by the recent
abdominal surgery. However, the fluid has markedly increased since last study
___ with notable peritoneal enhancement in the right lower abdomen
and within the pelvis. This is concerning for peritonitis. Free-fluid
secondary to bowel injury cannot be excluded given the lack of contrast within
the bowel.
LYMPH NODES: Reactive peritoneal lymph nodes more conspicuous compared to the
earlier study.
VASCULAR: No vascular occlusion. Normal caliber abdominal aorta.
PELVIS: Anteverted uterus. Post left salpingo-oophorectomy. Fluid in the cul
de sac surrounds the right ovary measures 6.6 x 8.1 cm demonstrates a rim
enhancement.
BONES:No acute osseous abnormality. Degenerative facet arthropathy lower
lumbar spine.
SOFT TISSUES: Subcutaneous soft tissue fat stranding in the periumbilical
region related to the laparoscopic surgery.
IMPRESSION:
1. Findings of small-bowel ileus with probable early mechanical small bowel
obstruction related to distal ileal loops ileitis secondary to the
inflammatory changes within the pelvis. NG tube placement would be beneficial
to decompress proximal small bowel loops.
2. Pneumoperitoneum, expected postsurgically.
3. Progression of moderate amount of free intraperitoneal fluid, some of which
appear rim enhancing within the pelvis concerning for an peritonitis within
the pelvis. Bowel injury cannot be excluded given lack of oral contrast
opacification. No biliary leak.
4. No acute pulmonary emboli or acute aortic syndrome.
NOTIFICATION: Wet read findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 5:28 am, 2 minutes after discovery of
the findings.
Findings were discussed with the gynecology resident at 09:20 twenty ___ by Dr. ___. Patient is planned to go to surgery with
concern of bowel injury during initial laparoscopic procedure.
Radiology Report
EXAMINATION: CT-GUIDED PIGTAIL DRAIN UPSIZE
INDICATION: ___ year old woman with pelvic drain// advance into fluid
collection
COMPARISON: Recent CT abdomen and pelvis from ___.
PROCEDURE: CT-guided pelvic drain upsize
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CT scan was performed to localize the pelvic collection. The
entry site with the pre-existing drain was chosen.
A 0.038 ___ wire was advanced into the preexisting 8 ___ pigtail
catheter; however, the ___ wire could not be advanced into the pelvic
collection. Hence the 8 ___ catheter and the ___ wire were pulled out.
10 cc of local anesthesia was administered with 1% Lidocaine solution. 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 5 cc of blood stained 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 8.1 s, 24.9 cm; CTDIvol = 15.8 mGy (Body) DLP = 382.2
mGy-cm.
2) Stationary Acquisition 5.8 s, 1.4 cm; CTDIvol = 60.2 mGy (Body) DLP =
86.7 mGy-cm.
3) Spiral Acquisition 10.0 s, 30.6 cm; CTDIvol = 15.1 mGy (Body) DLP =
441.1 mGy-cm.
Total DLP (Body) = 922 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 200 mcg fentanyl throughout the total intra-service time of 50
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Postprocedure CT confirmed adequate placement of the 10 ___ pigtail drain
into the now-evacuated pelvic collection.
IMPRESSION:
Successful CT-guided placement of ___ pigtail catheter into the pelvic
collection. Samples were sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with tracheostomy// interval change
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There are low lung volumes with crowding
of the part vascular markings of the lung bases. There is bibasilar
subsegmental atelectasis. There are no pneumothoraces.
Radiology Report
INDICATION: ___ year old woman with intubated// pna
COMPARISON: ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There are very low lung volumes with
atelectasis at the lung bases, unchanged. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubated// pna
IMPRESSION:
In comparison with the study of ___, there again are extremely low lung
volumes. Atelectatic changes are seen bilaterally. There is more
heterogeneous opacification at the left base silhouetting hemidiaphragm. In
the appropriate clinical setting, this would be worrisome for
aspiration/pneumonia.
Monitoring support devices are stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with trach, intubated// pna, ptx
IMPRESSION:
In comparison with the study of ___, there are slightly improved lung
volumes. Again there are bibasilar atelectatic changes, most prominent on the
left. Monitoring and support devices are unchanged.
In the appropriate clinical setting, would be very difficult to unequivocally
exclude superimposed aspiration/pneumonia, especially in the absence of a
lateral view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tracheostomy// interval change
IMPRESSION:
In comparison with the study of ___, there has been removal of the right
IJ catheter. Continued low lung volumes with retrocardiac opacification
consistent with volume loss in the lower lobe and small effusion and
atelectatic changes at the right base.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with prolonged immobility, new onset
tachycardia// DVT left upper extremity
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with prolonged immobility, new onset
tachycardia// 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.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ileus now s/p NG tube placement//
placement of NG tube
COMPARISON: CT dated ___
FINDINGS:
AP portable view of the chest provided.
The nasogastric tube ends at the gastroesophageal junction. Recommend
advancing at least 15 cm to ensure the side port is well within the stomach.
Lung volumes are low bilaterally. Blunting of the right costophrenic angle is
consistent with a small right pleural effusion. The small left pleural
effusion noted on CT is likely present, though outside the view of the current
study. Bibasilar linear opacities are consistent with atelectasis. There is
no pneumothorax. The heart size is mildly enlarged.
IMPRESSION:
1. Nasogastric tube ends at the gastroesophageal junction. Recommend
advancing the tube at least 15 cm to ensure the side port is below the
stomach.
2. Small right pleural effusion, unchanged. Small left pleural effusion is
also likely present though not imaged on the current study.
3. Bibasilar atelectasis, unchanged.
4. Mild cardiomegaly, unchanged.
NOTIFICATION: The findings were discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 10:54 am, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with trach now w/ increasing WBC and
tachycardia// evaluate acute pulmonary process
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___
IMPRESSION:
Compared to the examination from 3 days prior, there is interval increase of
right lung base atelectasis as well as development of a small layering
left-sided pleural effusion. Infection would be difficult to exclude given
the low lung volumes and areas of bibasilar opacity. A lateral view may be
helpful in further characterization if amenable. Lung volumes remain very
low. Support devices are unchanged in position. The upper lungs are clear.
Cardiomediastinal silhouette is unchanged. There is no pneumothorax.
Radiology Report
EXAMINATION: CT of the abdomen and pelvis with contrast
INDICATION: ___ year old woman s/p iatrogenic small bowel injury now s/p
ex-lap and multiple washouts, recently stopped abx. Now with new tachycardia
and leukocytosis// With PO and IV contrast. Evaluate for intra-abdominal leak
or abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 58.7 cm; CTDIvol = 12.4 mGy (Body) DLP = 729.4
mGy-cm.
2) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 27.9 mGy (Body) DLP =
14.0 mGy-cm.
Total DLP (Body) = 743 mGy-cm.
COMPARISON: CT of the abdomen and pelvis dated ___. CT images
from a drainage procedure dated ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with associated
atelectasis, left greater than right. The distal tip of a central venous
catheter is seen at the superior caval atrial junction. An enteric tube is
seen with tip in the stomach
ABDOMEN: There has been reaccumulation of a pelvic abscess since the last
drainage, but smaller in size from the prior study, (2:82) and now measures
6.5 x 2.4 cm. It previously measured 7.1 x 3.7 cm on ___. The
previously mentioned fluid collection along the greater curvature and lesser
curvatures of the stomach are no longer visualized.
The perisplenic fluid collections have decreased in size from the prior study
now measuring 6.1 x 1.1 cm (02:19). It previously measured 9.4 x 2.0 cm. A
loculated perihepatic fluid collection is not significantly changed in size
now measuring 8.6 x 2.1 cm which is thought to represent loculated ascites
rather than an abscess given the lack of peripheral enhancement (02:16).
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains high density
material similar to the prior study which may represent biliary sludge or
inspissated contrast.
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: An anterior abdominal wound is again noted. There is edema
of the underlying mesentery with fat stranding. Multiple small bowel loops
are again mildly prominent with some loops demonstrating mild wall thickening
which is decreased from the prior study but could be secondary to improving
peritonitis. 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: A Foley catheter is seen decompressing the urinary bladder. Trace
fluid is seen in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. The patient is status post
left oophorectomy. The previously discussed pelvic abscess is adjacent the
right adnexa, decreased in size from the prior study.
LYMPH NODES: There is an increased number of nonenlarged retroperitoneal and
mesenteric lymph nodes. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. Decrease in size of multiple fluid collections in the abdomen and pelvis,
the largest is a pelvic abscess which previously measured 7.1 x 3.7 cm and now
measures 6.5 x 2.4 cm.
2. No extraluminal contrast or free air is seen to suggest a leak.
3. Improvement in edema and mesenteric fat stranding in the anterior abdomen
with decrease in mildly prominent small bowel loops with mild wall thickening.
Findings likely represent improving peritonitis.
4. Bilateral pleural effusions with associated atelectasis.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman s/p multiple abd surgery s/p dobhoff
placement// dobhoff placement
TECHNIQUE: 2 frontal portable views of the chest.
COMPARISON: ___
IMPRESSION:
Compared to the examination from 2 days prior, there is been a replacement of
the upper enteric tube with Dobhoff tube tip terminating at least the level of
the mid to distal gastric body with tip outside of field-of-view. Otherwise
there is little interval change. Lung volumes remain very low with probable
small effusions and bibasilar atelectasis. Cardiomediastinal silhouette is
unchanged. Upper lung zones are clear. There is no pneumothorax. Left PICC
is unchanged.
Radiology Report
INDICATION: ___ year old woman with new RIJ CVL, new ETT, new NGT// confirm
line positions Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The patient is rotated. There has been interval intubation with the tip of
the endotracheal tube projecting over the mid thoracic trachea. An enteric
tube courses over the stomach. The tip of the right internal jugular central
venous catheter projects over the right atrium.
Markedly low lung volumes bilaterally. Asymmetric hazy opacification of the
right lung may reflect a layering pleural effusion and atelectasis. Similar
findings but to a lesser extent are present on the left. The size of the
cardiac silhouette appears enlarged, possibly secondary to low lung volumes
and AP portable technique.
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea, the
enteric tube projects over the stomach and the tip of the right internal
jugular central venous catheter projects over the right atrium.
Bilateral pleural effusions and overlying atelectasis, greater on the right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with sepsis intubated// assess lines tubes
lungs
COMPARISON: Chest radiographs from ___
FINDINGS:
The tip of the endotracheal tube is approximately 4 cm above the carina. The
nasogastric tube passes below the diaphragm and ends in the stomach. The
right IJ central line ends in the right atrium, as before.
Lung volumes are again low bilaterally. Bilateral basilar opacification is
unchanged. Compared to the ___ study, there is increased opacification
in the left hemithorax and decreased opacification of the right hemithorax.
This is consistent with a layering pleural effusion, now worse on the left.
Moderate pulmonary edema is unchanged. There is no pneumothorax. The heart
size is mildly enlarged, this could be exaggerated by low lung volumes and AP
portable techniques.
IMPRESSION:
1. Bilateral pleural effusions, now moderate on the left and small on the
right.
2. Moderate pulmonary edema, unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated// interval change
IMPRESSION:
In comparison with study of ___, there again are extremely low lung
volumes accentuating the size of the cardiac silhouette. The degree of
vascular congestion, pleural effusions, and compressive atelectasis are
probably stable. Monitoring and support devices are essentially unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Left lower quadrant pain
temperature: 97.5
heartrate: 110.0
resprate: 18.0
o2sat: 98.0
sbp: 113.0
dbp: 63.0
level of pain: 5
level of acuity: 3.0 | ___ is a ___ year old female who was admitted to the
hospital with left lower quadrant abdominal. She underwent
imaging and was noted to have a left ovarian cyst with concern
for torsion. She was taken to the operating room where she
underwent a laparoscopic left salpingo-oophorectomy, aspiration
of left ovarian cyst by gynecology on ___. She was initially
discharged home, but returned to the emergency department due to
increased abdominal pain. She was admitted to the gyn service at
that time. On ___ general surgery was urgently
consulted by the OB/GYN service. She was noted to be septic and
peritoneal and she was taken emergently to the operating room.
See op note for more details regarding the procedure. Briefly,
she underwent exploratory laparotomy with repair of small bowel
injury and placement of VAC sponge.
After the operation patient was transferred to the intensive
care unit. She was kept intubated and sedated. Patient was
febrile tachycardic and hypotensive and was put on pressors.
She was aggressively fluid resuscitated with adequate response.
Her blood cultures that were drawn from ___ where
shown to be growing GNRs. She was continued on the Cipro and
Flagyl. Pressors were weaned and she was massively fluid
resuscitated. Her lactate continued to trend down. She had an
___ drain placed for pelvic abscess on ___. However, due to
continued signs of sepsis, and concern for the output from her
abdominal wound vac which had become purulent, on ___ she
returned to the OR with general surgery and underwent
exploratory laparotomy with lysis of adhesions, open drainage of
multiple peritoneal abscesses, esophagogastroduodenoscopy, and
abdominal washout with application of negative pressure open
abdominal dressing with ABThera VAC. She had multiple areas of
abscess at the time of that surgery with extensive purulent
peritonitis, but she did not have any enterotomies or any leak
from the previously repaired bowel injury. She returned to the
OR ___ for another washout with drainage of multiple abscesses,
and vac change. On ___ she returned again and underwent
Exploratory laparotomy, washout, tightening ___ patch,
and with VAC placement, with the hope that we would subsequently
tighten the ___ patch. On ___ she returned to OR for
another washout and vac change, and at the time of this
operation the patient was observed to have developed an
enteroatmospheric fistula. Due to the densely frozen condition
of the bowel it was not possible to identify the exact site of
the fistula. Due to this fistula, the decision was made to
remove the ___ patch. On ___ she underwent reexploration
with ABThera/VAC placement. Due to prolonged intubation and
inability to wean from the vent on ___ she went to the
operating room for Tracheostomy (7 Portex), and also underwent
exploratory laparotomy with vac change. At this point there did
not appear to be any further leakage from the previously
discovered enteroatmospheric fistula. On ___ ___ advanced the
pelvic drain into better position for capture of persistent
abscess, and she returned to the OR and underwent skin grafting
from the right thigh onto the ___ the exposed bowel/open
abdomen. Her trach was also changed ___ the OR from a 7 to an 8
Portex. On ___, she underwent a charcoal test via NGT to
determine if the enteroatmospheric fistula had closed; the test
was negative for persistent leak and she subsequently went to
the OR for an additional skin graft from the left upper thigh to
fully cover the exposed bowel on ___. She returned to the OR on
___ then ___ for vac changes showing good take of the grafts
without need for further grafting.
Neuro: She remained sedated during her intubation with pain
medication. Her pain medication and sedation requirements to
keep her agitation at bay were high, antipsychotics were also
used. Since discharge from the intensive care unit, the patient
has been alert and oriented. Her clonidine has been slowly
weaned and should continue to be weaned to off.
Pulm: She remained intubated from the time of her initially
surgery on ___ until placement of her tracheostomy on ___.
Her vent support was gradually weaned until she was reliably on
trach mask starting on ___. On ___, she passed the ___-___
test and her trach was downsized from an 8 to a 6. Her trach
tube was removed on ___. A DSD has been kept over the site.
She has had no difficulty ___ breathing and she has maintained
her oxygen saturation at 98% room air.
CV: She was tachycardic throughout the first several weeks of
her hospital stay, which gradually improved as her sepsis
improved. She required intermittent beta-blockade with
metoprolol but this was discontinued prior to discharge with
normal heart rates. She was started on a clonidine patch and
later transitioned to oral clonidine. It is slowly being weaned
off. Her blood pressure has normalized but she still remains
tachycardic.
GI: The patient returned to the OR for multiple washouts and
evaluations for leaks. Initially no leaks were found, and so she
had drainage of multiple abscess cavities that were encountered
during repeat explorations. She underwent tube feed trials that
were halted due to worsening tachycardia and high residuals. She
was noted to have a leak during one of her takebacks, and so a
drain was placed over the leak. She was subsequently started on
TPN and octreotide. She was transitioned to TFs on ___ after
her charcoal leak test was negative, which she tolerated well
without signs of leak. Octreotide was discontinued at this time.
As she tolerated TFs at goal, her TPN was weaned and
discontinued on ___. The PICC line has remained ___ placed. She
was re-evaluated by speech/swallow and was allowed to start a
regular diet with thin liquids. She continues with cycled tube
feedings via the Dobhoff until her dietary intake improves, at
that time the Dobhoff can be removed.
GU: She had a foley placed during her initial operation that was
maintained for close UOP monitoring. Her fluid balance was
positive up to 30L at one point for measurable fluids, and ___
conjunction with her significant pitting edema and stable blood
pressure, she was started on intermittent IV Lasix diuresis,
with excellent response until she was euvolemic and this was
discontinued. Her foley was discontinued on ___ and she voided
thereafter without issue.
Heme: She remained on DVT prophylaxis. She was transfused as
needed per transfusion protocol.
ID: She was maintained on broad spectrum antibiotics, which
after initial operation were cipro/flagyl. This was broadened to
vancomycin/unasyn after cultures grew strep anginosus and
enterococcus. She was narrowed to unasyn after both organisms
were found unasyn-sensitive, which was ultimately switched to
augmentin. She has completed her course of antibiotics. Her
white blood cell count has normalized and she has been afebrile.
EXT: No swelling ___ lower extremities. She underwent an US of
the lower extremities for a new onset of tachycardia. There was
no evidence of deep venous thrombosis ___ the right or left lower
extremity veins.
SKIN: Quarter size ulceration left buttock, meplex dressing
applied
The patient was evaluated by physical therapy and
recommendations made for discharge to a rehabilitation center to
help her regain her strength and mobility. The patient was
discharge on ___ ___ stable condition. Discharge instructions
were reviewed and questions answered. Appointments for
follow-up were made with the GYN and acute care surgery clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Evista / ketoprofen / omeprazole / Penicillins / simvastatin /
tizanidine / Zometa
Attending: ___.
Chief Complaint:
dyspnea, acute on chronic hypercapnic respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with PMHx of HFpEF (TTE
___ EF 65%), A. fib on apixiban, CKD Stage III, DM, who
initially presented to ___ for lethargy and SOB, and now
subsequently transferred to ___ for ICU bed in setting of
hypercapnic respiratory failure requiring BiPAP.
Patient initially presented from ___ (___ at
___ to ___ with 1 day of dyspnea and lethargy. On
arrival to ___, she was tachypneic to the ___ and unable
to complete full sentences. History was limited as patient had
altered mental status and was not fully able to participate in
interview. She had chest x-ray which showed volume overload as
well as opacity concerning for pneumonia. She was noted to be
febrile to 100.4. Labs at ___ were notable for BNP of 20,000
and white count of 12. UA was negative. She had an ABG with
7.32/100/74. She received cefepime and 40 mg furosemide IV and
was started on BiPAP. Transfer to ___ was initiated given lack
of ICU beds at ___.
On arrival to ___ ED, she was tachypneic to ___ and agitated
on
the BiPAP mask. Foley was noted to have 600cc urine. She was
trialed off BiPAP; VBG off BiPAP was obtained which resulted
7.28/80. Given agitation with BiPAP she was transitioned to ___
prior to transfer to ___.
In the ED,
- Initial Vitals:
HR 83 BP 134/69 RR18 O2-99 RA
- Exam:
GENERAL: Agitated, combative, and soft restraints
HEENT: NCAT, moist mucous membranes
CV: RRR, s1/s2, no s3/s4, no m/r/g, radial pulses equal
bilaterally, skin warm and well perfused
PULM: Lung exam limited by agitated status, no frank rales, no
accessory mm. use
ABDOMINAL: NTND, no rebound/guarding, no peritonitic signs
GU: no CVAT
MSK: Full ROM, no joint swelling, no erythema
EXTREMITIES: 1+ pitting edema bilateral lower extremity
NEURO: freely moving all extremities
- Labs: BNP 24864 Trop 0.04 CKMB 2 VBG off BiPAP ___
- Imaging: CXR - Potential left basilar patchy opacity, which
may
reflect atelectasis with infection not excluded, though
assessment is limited without a lateral view.
- Interventions: none
Upon arrival to the FICU, she is intermittently alert and
oriented. She states that she is in the hospital due to having
too much fluid. She endorses SOB and cough. Denies any sputum
production. She denies chest pain, abdominal pain, constipation,
diarrhea, or dysuria, no bleeding.
Past Medical History:
CHF
Afib (on apixiban)
CKD Stage 3
HTN
T2DM
Hypothyroidism
GERD
Bilateral hip replacement
Remote left breast cancer
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.2 HR81 BP106/37 RR26 O2:100
GEN: sleepy, tachypneic, in NAD
HENNT: PEERL, EOMI, no icterus, MMM
CV: irregular rate and rhythm, no M/R/G, JVD elevated
RESP: bibasilar crackles + rhonchi
GI: soft, non-tender, non-distended, no rebound/guarding
EXT: 2+ bilateral pitting ___
NEURO: oriented to place, month and year; face symmetric, moving
all extremities
DISCHARGE PHYSICAL EXAM
========================
97.4 BP:119/61 HR:68 R:20 o2:93% RA
GENERAL: Alert and in no apparent distress, speaking in full
sentences
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Hard of
hearing
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Clear on anterior auscultation
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes noted
NEURO: Alert, face symmetric, gaze conjugate with EOMI, speech
fluent, moves all limbs, sensation to light touch grossly intact
throughout. AAO X 3. Knows day of week and able to ___
backwards.
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
==============
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:27PM ___ PO2-27* PCO2-80* PH-7.28* TOTAL
CO2-39* BASE XS-5
___ 10:27PM LACTATE-1.3
___ 10:20PM GLUCOSE-100 UREA N-29* CREAT-1.1 SODIUM-145
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-36* ANION GAP-12
___ 10:20PM cTropnT-0.04*
___ 10:20PM CK-MB-2 ___
___ 10:20PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.5*
___ 10:20PM WBC-13.0* RBC-3.43* HGB-8.5* HCT-30.2* MCV-88
MCH-24.8* MCHC-28.1* RDW-19.3* RDWSD-62.4*
___ 10:20PM NEUTS-78.9* LYMPHS-8.7* MONOS-10.1 EOS-1.0
BASOS-0.3 IM ___ AbsNeut-10.28* AbsLymp-1.13*
AbsMono-1.32* AbsEos-0.13 AbsBaso-0.04
MICRO/OTHER PERTINENT LABS
==========================
___ 02:34AM BLOOD Ret Aut-2.4* Abs Ret-0.08
___ 10:20PM BLOOD CK-MB-2 ___
___ 10:20PM BLOOD cTropnT-0.04*
___ 02:34AM BLOOD Iron-11*
___ 02:34AM BLOOD calTIBC-228* VitB12-777 Ferritn-257*
TRF-175*
___ 10:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING
========
CXR ___
Potential left basilar patchy opacity, which may reflect
atelectasis with
infection not excluded, though assessment is limited without a
lateral view.
CXR ___:
In comparison with the study of ___, the there again is
substantial
enlargement of the cardiac silhouette with some improvement in
the degree of pulmonary edema. The right hemidiaphragmatic
contour is more sharply seen, consistent with improving pleural
effusion. Retrocardiac opacification again is consistent with
volume loss in the left lower lobe and pleural fluid.
Round opacification in the left humeral head most likely
represents a benign bone island. If the patient has a condition
associated with sclerotic metastases, further imaging could be
obtained if clinically warranted.
CXR: ___
IMPRESSION:
Interval improvement in the degree of pulmonary vascular
congestion. Stable bilateral pleural effusions.
ECG: ___
Typical atrial flutter with variable conduction and isolated
premature
ventricular contractions versus aberrantly conducted ventricular
complexes.
Underlying right bundle-branch block. Compared to the previous
tracing of
___ the rhythm is more organized and consistent with atrial
flutter.
The ventricular response is controlled.
DISCHARGE LABS
===============
___ 07:50AM BLOOD WBC-8.2 RBC-3.66* Hgb-8.8* Hct-31.1*
MCV-85 MCH-24.0* MCHC-28.3* RDW-18.2* RDWSD-56.9* Plt ___
___ 06:12AM BLOOD ___ PTT-31.3 ___
___ 08:00AM BLOOD Glucose-102* UreaN-28* Creat-1.3* Na-141
K-4.8 Cl-95* HCO3-37* AnGap-9*
___ 10:20PM BLOOD CK-MB-2 ___
___ 10:20PM BLOOD cTropnT-0.04*
___ 08:00AM BLOOD proBNP-3821*
___ 02:34AM BLOOD calTIBC-228* VitB12-777 Ferritn-257*
TRF-175*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QHS
2. Cetirizine 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
5. Multivitamins 1 TAB PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Cyanocobalamin 250 mcg PO DAILY
8. Docusate Sodium 100 mg PO DAILY
9. Mirtazapine 15 mg PO QHS
10. Apixaban 5 mg PO BID
11. Gabapentin 100 mg PO BID
12. Furosemide 40 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Acute on chronic diastolic CHF exacerbation
Atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with HF exac, pna// eval consolidation
TECHNIQUE: Upright AP view of the chest
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is mildly enlarged. Atherosclerotic calcifications
are seen involving the aortic knob. Mediastinal and hilar contours are
otherwise unremarkable. Pulmonary vasculature is not engorged. Lung volumes
are low. Left basilar opacification may be present, though difficult to
assess without a lateral view. Right lung is grossly clear. No pneumothorax.
No large pleural effusion. No acute osseous abnormality.
IMPRESSION:
Potential left basilar patchy opacity, which may reflect atelectasis with
infection not excluded, though assessment is limited without a lateral view.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with pneumonia, CHF, new right sided heart
failure// please eval for evidence of continued volume overload or other
abnormalities.Comparison CXR for V/Q scan
TECHNIQUE: Chest PA and lateral view
COMPARISON: ___
IMPRESSION:
Pulmonary edema has worsened. Cardiomediastinal silhouette is stable.
Bilateral effusions right greater than left are unchanged. No pneumothorax is
seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, presented with respiratory failure,
found to have evidence of volume overload// please eval for continuing volume
overload or other abnormalities
IMPRESSION:
In comparison with the study of ___, the there again is substantial
enlargement of the cardiac silhouette with some improvement in the degree of
pulmonary edema. The right hemidiaphragmatic contour is more sharply seen,
consistent with improving pleural effusion. Retrocardiac opacification again
is consistent with volume loss in the left lower lobe and pleural fluid.
Round opacification in the left humeral head most likely represents a benign
bone island. If the patient has a condition associated with sclerotic
metastases, further imaging could be obtained if clinically warranted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, atrial flutter, now with cough,
evaluate for volume overload.
TECHNIQUE: Chest AP
COMPARISON: Comparison to prior radiograph studies dated ___, and ___.
FINDINGS:
The cardiomediastinal silhouette is enlarged. The lung volumes are decreased.
There is interval improvement in the degree of pulmonary vascular congestion.
There are stable bilateral pleural effusions. Retrocardiac opacification is
again seen in the left lower lobe consistent with underlying effusion and
associated atelectasis. There is mild tortuosity of the descending aorta.
There is no acute focal consolidation. There is no pneumothorax.
IMPRESSION:
Interval improvement in the degree of pulmonary vascular congestion. Stable
bilateral pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Heart failure, unspecified, Other pneumonia, unspecified organism, Anemia, unspecified, Dyspnea, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 2.0 | PA andMs. ___ is a ___ woman with PMHx of HFpEF
(TTE ___ EF 65%), afib on apixiban, CKD Stage III, DM, who
initially presented to ___ for lethargy and
SOB, and was subsequently transferred to ___ ICU due to
hypercapnic respiratory failure requiring BiPAP.
# Acute on likely chronic hypercapnic respiratory failure
# Acute HFpEF exacerbation
# Fever, leukocytosis. Severe sepsis with ___
Presented with hypoxia as well as acute on chronic hypercapnia
(pCO2 ___ with pH 7.27-7.28). She has history of elevated HCO3
in outpatient labs suggestive of chronic compensation for
respiratory acidosis. She was trialed on BIPAP in the ICU with
no significant improvement in CO2 retention. There was no clear
cause of chronic respiratory acidosis and she has no known COPD.
She was found to be volume overloaded with likely pneumonia
resulting in hypoxia at time of presentation.
As mental status improved (see below) her VBG improved to a pH
7.37 with pCO2 65,
likely baseline. Some degree of acute respiratory acidosis may
have been related to lethargy/somnolence. TTE was obtained and
was suggestive of right sided heart failure and severe pulmonary
hypertension. This appears new compared to prior TTE from ___
in ___ system. V/Q scan was obtained to evaluate for PE given
new right heart failure but was non-diagnostic (ventilation
images unable to be obtained). Overall PE was felt to be
unlikely given that she is chronically on apixaban and the
elevated pulmonary pressures were likely due at least in part to
volume overload. CXR was unable to rule out pneumonia and she
was febrile at time of admission though this may have been due
to aspiration. She was initially treated with
vanc/cefepime/azithromycin which was narrowed to
ceftriaxone/azithromycin to complete a 5 day course. She was
diuresed with IV lasix boluses. And subsequently transitioned
to oral torsemide. Her volume status was difficult to obtain as
the patient cannot stand for weights. And is incontinent
therefore ins and outs were not well documented. Chest x-rays
and BNP's were followed. Chest x-ray improved and BNP trended
down from ___ on admission to 3821 on the day of discharge.
The patient's creatinine was slightly elevated on discharge
indicating she is likely hypovolemic. With therefore
recommending holding torsemide and repeating chemistry on
___ if creatinine is less than 1 would resume torsemide 20
mg p.o. daily.
#Encephalopathy/Delirium
Presented with lethargy. Likely toxic metabolic in the setting
of respiratory failure and pneumonia. Improved with treatment of
respiratory failure and possible pneumonia as above. The
patient improved and was awake alert and oriented x3 on
discharge she knew the day of the week and was able to do the
months of the year backwards fluently.
# ___ on CKD
Cr 0.8 on last admission to ___ and elevated to 1.3 here.
Likely pre-renal in setting of acute CHF exacerbation. Improved
to baseline with diuresis and then began to rise again
indicating the patient was likely hypovolemic/over diuresed. On
discharge would hold the patient's diuretics repeat creatinine
on ___ and if creatinine is less than 1.1 at that
time start torsemide 20 mg p.o. daily.
# Atrial flutter:
The patient's dose of metoprolol was decreased on admission her
she then developed rapid atrial flutter and her dose of
metoprolol was increased with improved control. Apixiban was
continued for anticoagulation. If the patient has ongoing rapid
rates can consider addition of digoxin versus cardioversion.
The patient has cardiology follow-up arranged on discharge.
# Anemia
Hg at baseline. Low iron saturation suggestive of iron
deficiency Can consider IV iron prior to discharge.
# Elevated INR: INR 3.1 on admission, improved to 2.7 with IV
vitamin K. Does take apixaban. She was started on a PO vitamin K
challenge with 5mg PO X 3 days with decrease in INR to 2.4.
# GOC:
Reviewed with the patient and her nephew. The patient is
DNR/DNI. The patient had been seen by speech-language pathology
during her hospitalization who recommended a modified diet. The
patient and her nephew preferred to allow the patient to eat for
comfort the patient should be on thin liquids with a soft solid
diet
# GERD: continued home omeprazole
# DM
Not on home insulin. Monitored
TRANSITIONAL ISSUES
====================
- Please check Chem 7 on ___. If Creatinine is less than 1.1
start Torsemide 20mg daily
- Patient should follow up with cardiology- to be contacted with
appointment
# Code Status: DNR/DNI, ok for NIV
# Emergency Contact: ___, nephew, ___, HCP
>30 minutes on discharge activities. |
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, acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with h/o CAD s/p CABG, carotid stenosis s/p CEA and HTN
presents with RLE pain and new ___. Patient is a poor
historian, but per records and his report, he was taken by his
son to the cardiologist today after experiencing pain in his
right lateral thigh and calf. Per son, he has had more
difficulty walking lately. He was taken from clinic to ___
___, where his pain symptoms had resolved but there was
concern for vascular occlusion to that leg. On arrival his BP
was ___, which improved with fluids. He was also
incidentally noted to have renal failure, with Cr 4.89 and BUN
135 and hyperkalemia to 6.7. He was treated with kayexalate,
calcium gluconate, insulin and D50. CXR normal. He was then
transferred to ___ for vascular surgery evaluation and work up
of his renal failure.
.
On arrival in the ED, his initial vitals were 97.1, 85, 140/56,
12, 97%. Here he denies leg pain or weakness, chest pain
shortness of breath syncope or presyncope. Exam was notable for
cool RLE but with dopplerable pulses. Labs were notable for
grossly abnormal chem panel with Cr 4.2, BUN 118, K 5.2, bicarb
13, anion gap 16. CBC showed hct of 26.6 (consistent from
values from ___. EKG showed peaked T waves and RBBB (new from
___ but no interval EKG for comparison). Urgent vascular
surgery consult obtained, who felt that there this was most
likely musculoskeletal rather than vascular etiology. He was
then admitted to medicine for work up.
.
On arrival to the floor, patient is lying in bed and in no acute
distress. Denies any pain, confusion, itching. Does not believe
he's gained any weight recently, is not feeling more fatigued,
but does say his belly sometimes swells. Has noticed decreased
urine output in last day.
.
ROS: negative unless otherwise stated in HPI
Past Medical History:
CAD s/p CABG in ___ (LIMA>LAD, SVG>OM)
Systolic CHF - EF 35-40% on TTE in ___
COPD
HTN
PVD
Carotid stenosis s/p right carotid endarterectomy
PAF
Chronic renal insufficiency
Social History:
___
Family History:
No family history of kidney disease or cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.7F, BP 119/50, HR 88, RR 20, O2-sat 99% RA
___ - cachectic appearing elderly man, in no acute distress
HEENT - NC/AT, anisocoria L>R with left eye cataract, EOMI,
sclerae anicteric, dry mucous membranes, white coating on tongue
(?thrush)
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, ___ systolic murmur heard best
at apex, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, pulsatile aorta felt in mid-abdomen,
bruit heard throughout mid abdomen (unable to clearly locate)
EXTREMITIES - BLE cool to touch, faint peripheral pulses but
able to doppler
SKIN - scattered seborrheic keratoses across chest
NEURO - awake, A&Ox3, CNs II-XII grossly intact (although has
trouble following commands)
Pertinent Results:
LABS:
On admission:
___ 06:05PM BLOOD WBC-6.2 RBC-2.86* Hgb-9.3* Hct-26.6*
MCV-93# MCH-32.6*# MCHC-35.0 RDW-14.3 Plt ___
___ 06:05PM BLOOD Neuts-74.4* Lymphs-16.9* Monos-7.4
Eos-0.9 Baso-0.4
___ 06:05PM BLOOD ___ PTT-22.0* ___
___ 06:05PM BLOOD Glucose-95 UreaN-118* Creat-4.2*# Na-146*
K-5.2* Cl-117* HCO3-13* AnGap-21*
___ 06:05PM BLOOD cTropnT-0.02*
On discharge:
___ 06:30AM BLOOD WBC-7.5 RBC-2.96* Hgb-9.2* Hct-26.7*
MCV-90 MCH-31.1 MCHC-34.4 RDW-15.3 Plt ___
___ 06:30AM BLOOD Glucose-123* UreaN-60* Creat-2.3* Na-141
K-3.9 Cl-112* HCO3-23 AnGap-10
___ 06:30AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.2
URINE CYTOLOGY:
POSITIVE FOR MALIGNANT CELLS consistent with high grade
urothelial carcinoma.
Highly atypical urothelial cells present singly and in clustes.
Neutrophils and red blood cells.
IMAGING:
___ Renal US (Pre foley catheter):
1. Bilateral hydronephrosis, moderate on the right and mild on
the left. No definite obstructing lesion seen within the
proximal ureters.
2. Echogenic vascular material in the region of the right
ureterovesical junction, a possible intraluminal polypoid mass
or secondary to protrusion of the median lobe of the prostate
gland against the bladder wall. Urologic consultation is
recommended for further evaluation.
3. Moderately calcified non-aneurysmal abdominal aorta.
___ Renal US (post foley):
Mild right-sided pelvic ectasia without overt hydronephrosis,
improved from the prior examination. Resolution of left-sided
hydronephrosis.
Possible right distal hydroureter.
___ CT abdomen/pelvis:
IMPRESSION:
1. Limited assessment for bladder mass given the lack of
intravenous contrast material and foley causing complete
collapse. The external bladder contour is grossly normal.
2. Right renal caliectasis as well as a right extrarenal pelvis,
corresponding to findings seen on renal ultrasound from ___.
3. Ectasia of the abdominal aorta at the level of the renal
arteries with
aneurysmal dilatation just inferior to this level, measuring up
to 3.5 cm in diameter.
4. Tiny quantity of free fluid in the left paracolic gutter is a
nonspecific finding.
5. No evidence of a retroperitoneal hematoma.
Medications on Admission:
Lipitor 80 mg qday
Metoprolol tartrate 25mg PO BID
Aspirin 81 mg daily
___ 75 mg qday
Klor-con 10meq daily
Lasix 20mg QOD
Lisinopril 20mg daily
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Acute on chronic renal failure
Bladder cancer
Upper GI bleed
Gastritis
Hyperkalemia
Anemia
Secondary diagnoses:
Coronary artery disease
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: ___ male presenting with new onset acute renal failure.
COMPARISON: None available in the ___ system.
RENAL ULTRASOUND: The examination is extremely limited due to patient body
habitus and limited acoustic window. Doppler evaluation could not be
completed due to patient's inability to breath-hold. The right kidney
measures 10.6 cm, and the left kidney measures 9.6 cm. There is bilateral
hydroureteronephrosis, moderate on the right and mild on the left. No clear
obstructing lesion is identified within the proximal ureters. No suspicious
renal mass or stone is visualized in either kidney. The bladder is markedly
distended. Additionally, in the region of the distal right ureterovesical
junction, there is a vascular echogenic focus which may represent an
intraluminal polypoid mass or possibly a protrusion of the median lobe of the
prostate gland. Urologic consultation is recommended for further evaluation.
The abdominal aorta is calcified throughout its course, though non-aneurysmal.
IMPRESSION:
1. Bilateral hydronephrosis, moderate on the right and mild on the left. No
definite obstructing lesion seen within the proximal ureters.
2. Echogenic vascular material in the region of the right ureterovesical
junction, a possible intraluminal polypoid mass or secondary to protrusion of
the median lobe of the prostate gland against the bladder wall. Urologic
consultation is recommended for further evaluation.
3. Moderately calcified non-aneurysmal abdominal aorta.
Dr. ___ communicated the preliminary findings to Dr. ___ at
1:45 am on ___ by telephone.
Radiology Report
___ male with right leg pain.
Bilateral lower extremity ABIs, Doppler waveforms, and PVRs were performed at
rest.
FINDINGS:
RIGHT: ABIs were not calculable due to lack of dopplerable signal in the
foot. The femoral, superficial femoral, and popliteal waveforms are
monophasic. Pulse volume recordings show significant artifact, but suggest
severe lower extremity ischemia with aphasic waveforms at the metatarsal
level.
LEFT: Left ABIs could not be calculated due to absent ankle signals. The
femoral, superficial femoral, and popliteal waveforms are monophasic and
blunted. Pulse volume recordings are symmetric when compared to the right and
show additional tibial disease with aphasic metatarsal waveforms.
IMPRESSION: Severe bilateral lower extremity peripheral vascular disease with
evidence of aortoiliac and additional tibial occlusive disease. Severe
forefoot ischemia.
Radiology Report
INDICATION: New acute renal insufficiency with hydronephrosis and possible
bladder mass seen on prior ultrasound. Evaluation for interval change.
TECHNIQUE: Renal sonogram.
COMPARISON: Ultrasound dated ___ obtained approximately 14 hours
prior.
FINDINGS: The right kidney measures 9.5 cm and demonstrates mild pelvic
ectasia without hydronephrosis, improved from the prior examination. The left
kidney measures 9.5 cm and appears grossly normal with resolved
hydronephrosis. The bladder is collapsed around a Foley catheter and not well
evaluated. A dilated structure adjacent to the right aspect of the bladder
may represent right-sided hydroureter. Cholelithiasis is seen within the
partially imaged gallbladder.
IMPRESSION: Mild right-sided pelvic ectasia without overt hydronephrosis,
improved from the prior examination. Resolution of left-sided hydronephrosis.
Possible right distal hydroureter.
Radiology Report
INDICATION: Acute renal failure with hydronephrosis and new bladder mass,
also with 4-point hematocrit drop today. Assess bladder mass and possible
source of bleeding.
TECHNIQUE: MDCT axial images were acquired from the lung bases through the
lesser trochanters following the administration of oral contrast material
only. Multiplanar reformations were performed.
COMPARISON: Renal ultrasound from ___.
ABDOMEN CT: There is minimal bibasilar dependent atelectasis, left greater
than right, as well as evidence of possible mild fibrosis in the left lower
lobe (2:6). Relative hypodensity of the intraventricular blood compared to
the myocardium is consistent with anemia.
Lack of intravenous contrast material limits assessment of the abdominal
organs. The liver is grossly unremarkable. The gallbladder has simple
cholelithiasis. The pleen, pancreas, adrenal glands, and left kidney are
grossly normal. There is an extrarenal pelvis on the right with mild fullness
of the collecting system. Mild perinephric stranding is noted bilaterally,
without an associated collection. The stomach is full of oral contrast
material and digested food, although not particularly distended. The small
bowel is grossly unremarkable. There is scattered colonic diverticulosis
without evidence of diverticulitis. The appendix is normal. There may be a
tiny quantity of free fluid in the left paracolic gutter (2:39). There is no
free air in the abdomen. No pathologically enlarged abdominal lymph nodes are
seen. The abdominal aorta is ectatic at the level of the renal arteries
(2:23), measuring up to 3.2 cm, and focally aneurysmal just inferior to the
level of the renal arteries, measuring up to 3.5 cm (300B:24). The proximal
portion of the left common iliac artery is ectatic, measuring 15 mm in caliber
(2:46). Diffuse calcifications throughout the aorta and bi-iliac arteries are
noted. There is no evidence of a retroperitoneal hematoma.
PELVIS CT: Lack of intravenous contrast material limits assessment of the
pelvic organs. The bladder is somewhat collapsed around a Foley catheter.
Circumferential bladder wall thickening could relate to underdistension.
Evaluation for a bladder mass is not possible, although the external bladder
contour is normal in appearance. The prostate is unremarkable. There is no
free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are
seen.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
Multilevel degenerative changes of the thoracolumbar spine are noted.
IMPRESSION:
1. Limited assessment for bladder mass given the lack of intravenous contrast
material and foley causing complete collapse. The external bladder contour is
grossly normal.
2. Right renal caliectasis as well as a right extrarenal pelvis,
corresponding to findings seen on renal ultrasound from ___.
3. Ectasia of the abdominal aorta at the level of the renal arteries with
aneurysmal dilatation just inferior to this level, measuring up to 3.5 cm in
diameter.
4. Tiny quantity of free fluid in the left paracolic gutter is a nonspecific
finding.
5. No evidence of a retroperitoneal hematoma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RLL OCCLUSION
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERKALEMIA
temperature: 97.1
heartrate: 85.0
resprate: 12.0
o2sat: 97.0
sbp: 140.0
dbp: 56.0
level of pain: nan
level of acuity: 2.0 | ___ yo M with h/o CAD s/p CABG, carotid stenosis s/p CEA and HTN
admitted with RLE pain (now resolved) and new renal failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
___ year-old man with past medical of renal cell carcinoma
(diagnosed ___, T2N0Mx, Stage II, s/p right nephrectomy, clear
cell renal cell carcinoma, metastatic to the mediastinal lymph
nodes in ___, s/p high-dose IL-2 in ___ with complete
response, left adrenal metastasis ___ s/p adrenalectomy,
recurrence in mediastinal lymph nodes ___, s/p right VATS and
mediastinal lymph node excision, with slowly-progressive right
upper and middle lobe clustered nodules and interlobular septal
thickening beginning in ___, with further progression in this
area noted ___ and ___, recently began treatment on
clinical trial protocol ___, randomized to the I-3 arm of
ipilimumab 3 mg/kg and nivolumab 1 mg/kg), carotid stenosis s/p
carotid endartectomy, diabetes mellitus, hypertension,
hyperlipidemia, and post-surgical adrenal insufficiency.
He was sent to the ED after informing his primary oncologist
stating that he has had diarrhea (up to 4 times per day) for the
past two days, vomiting
multiple times earlier the day of admission, and the sensation
of "dehydration."
In the ED inital vitals were: T 99.7 HR: 91 BP: 113/58 Resp: 18
O(2)Sat: 96 and stable throughout his stay in the ED. Abdomen
was soft, non-distended, mild ttp ___ area. CBC, chem
7 and LFT were unremarkable except lipase of 500. He received 2
L IVF, IV zofran and was admitted for further care and
management.
Past Medical History:
Past Oncologic History:
renal cell carcinoma (diagnosed ___, T2N0Mx, Stage II, s/p
right nephrectomy, clear cell renal cell carcinoma, metastatic
to the mediastinal lymph nodes in ___, s/p high-dose IL-2 in
___ with complete response, left adrenal metastasis ___ s/p
adrenalectomy, recurrence in mediastinal lymph nodes ___, s/p
right VATS and mediastinal lymph node excision, with
slowly-progressive right upper and middle lobe clustered nodules
and interlobular septal thickening beginning in ___, with
further progression in this area noted ___ and ___,
recently began treatment on clinical trial protocol ___,
randomized to the I-3 arm of ipilimumab 3 mg/kg and nivolumab 1
mg/kg)
Other Past Medical History:
- DM
- HTN
- Hyperlipidemia
- Carotid stenosis s/p carotid endartectomy
- post-surgical adrenal insufficiency
PSH:
- Right nephrectomy ___
- Umbilical hernia repair
- Excision squamous cell ca of nose
Social History:
___
Family History:
Mother, breast cancer, deceased
Brother, multiple sclerosis, deceased
No history of autoimmune or thyroid conditions in family
Physical Exam:
Admission physical exam:
VS: 98.1, 115/60, 68, 18, 96% on RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR, S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NTND, no rebound/guarding, no HSM, no ___
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising, numerous nevi scattered over back
and torso
Neuro: AOx3, grossly nonfocal, ___ strength of BUE/BLE.
Sensation grossly intact. Gait normal.
Discharge physical exam:
VS 97.5 150/80 56 18 99% RA FSBG 197-300.
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR, S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: BS+, soft, NTND, mild discomfort with deep palpation of
lower quadrants, no rebound/guarding, no HSM, no ___ sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising, numerous nevi scattered over back
and torso
Neuro: AOx3, grossly nonfocal, ___ strength of BUE/BLE.
Sensation grossly intact. Gait normal.
Pertinent Results:
Admission labs:
--------------
___ 11:05AM BLOOD WBC-6.4 RBC-4.95 Hgb-14.3 Hct-43.1 MCV-87
MCH-28.8 MCHC-33.1 RDW-13.6 Plt ___
___ 07:30AM BLOOD ___ PTT-32.2 ___
___ 11:05AM BLOOD Glucose-149* UreaN-25* Creat-1.1 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
___ 11:05AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.7
___ 11:41AM BLOOD Lactate-1.8
Discharge labs:
---------------
___ 08:15AM BLOOD WBC-6.3 RBC-4.49* Hgb-12.5* Hct-39.2*
MCV-87 MCH-27.8 MCHC-31.8 RDW-13.8 Plt ___
___ 08:15AM BLOOD Plt ___
___ 08:15AM BLOOD Glucose-183* UreaN-17 Creat-0.9 Na-142
K-3.8 Cl-105 HCO3-31 AnGap-10
___ 08:15AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
___ 08:00AM BLOOD QUANTIFERON-TB GOLD-PND
Microbiology:
-------------
Blood Culture, Routine (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___: Positive
for toxigenic C. difficile by the Illumigene DNA amplification.
OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN.
HCV VIRAL LOAD (Final ___: HCV-RNA NOT DETECTED
Imaging:
--------
___ KUB No evidence of bowel dilation or obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. Glargine 20 Units Bedtime
3. Aspirin 81 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. PredniSONE 7.5 mg PO DAILY
6. Fludrocortisone Acetate 0.1 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN knee
pain
8. Hydrocortisone Na Succ. 100 mg IV ONCE
9. Viagra (sildenafil) 100 mg oral daily sexual activity
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 5 ML by mouth every 6 hours Disp #*280
Millimeter Refills:*0
2. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) 24
unit subcutaneous at bedtime Disp #*30 Syringe Refills:*1
RX *insulin lispro [Humalog KwikPen] 100 unit/mL as directed
unit subcutaneous four times daily per sliding scale Disp #*45
Syringe Refills:*2
3. Aspirin 81 mg PO DAILY
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Hydrocortisone Na Succ. 100 mg IV ONCE PRN Duration: 1 Dose
6. Simvastatin 20 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Viagra (sildenafil) 100 mg oral daily sexual activity
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN knee
pain
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth daily at bed
time Disp #*30 Tablet Refills:*0
11. PredniSONE 10 mg PO DAILY
take 6 tablets daily for 7 days, then decrease 1 tablet every 7
days
Tapered dose - DOWN
RX *prednisone 10 mg as directed tablet(s) by mouth daily Disp
#*150 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Presumed chemotherapy-associated autoimmune colitis
Diarrhea
C diff
Diabetes Mellitus type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with metastatic renal cell carcinoma, presenting
with fever. Assess for PNA. // ?PNA
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest radiographs dated ___ through ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates well expanded clear
lungs. The cardiomediastinal and hilar contours are unchanged. There is no
pneumothorax, pleural effusion, or consolidation. The upper most apices are
obscured by the patient's head.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with metastatic renal cell carcinoma, presenting
with diarrhea, found to have C. diff. Assess for any colonic dilatation. //
?colonic dilatation
TECHNIQUE: Portable radiographs of the abdomen
COMPARISON: Comparison is made to CT abdomen and pelvis dated ___.
FINDINGS:
The bowel gas pattern is nonspecific and nonobstructive. There are no
abnormally dilated loops of small or large bowel. Within the limitation of
supine radiographs, there is no evidence of pneumatosis or pneumoperitoneum.
Multilevel degenerative changes of the visualized thoracolumbar spine are
noted.Multiple surgical clips are seen projecting over the mid abdomen.
IMPRESSION:
No evidence of bowel dilation or obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Abd pain
Diagnosed with ABDOMINAL PAIN PERIUMBILIC, NAUSEA WITH VOMITING, DIARRHEA
temperature: 99.7
heartrate: 91.0
resprate: 18.0
o2sat: 96.0
sbp: 113.0
dbp: 58.0
level of pain: 7
level of acuity: 2.0 | ___ PMH RCC (s/p right nephrectomy, clear cell RCC, mets to
mediastinal LN ___, s/p high-dose IL-2 ___ with complete
response, left adrenal mets ' ___ s/p adrenalectomy and
post-surgical adrenal insufficiency, recurrence in mediastinal
lymph nodes ___, s/p right VATS and mediastinal lymph node
excision, with slowly-progressive right upper and middle lobe
clustered nodules and interlobular septal thickening beginning
in ___, with further progression in this area noted ___
and ___, recently began treatment on clinical trial protocol
___, randomized to the I-3 arm of ipilimumab 3 mg/kg and
nivolumab 1 mg/kg), carotid stenosis s/p carotid endartectomy,
DM, HTN, HL presents with vomiting, diarrhea and abdominal pain.
# Vomiting/diarrhea/abdominal pain: Patient found to have C.
diff, but given limited to response to PO vancomycin x 48 hours,
concern for ipilimumab-associated autoimmune colitis was raised.
Was placed on 45 mg methylprednisolone BID with dramatic
response (<4BM/day).Was transitioned to 100mg Prednisone daily
PO and then to 60mg daily at discharge with plan for 6 week
taper of 10 mg less per week.
# Post-op adrenal isufficiency: patient was continued on home
dose of fludricortisone with no episodes of hemodynamic
instability.
# DM: Patient was started on home dose of lantus 20u QHS. Once
steroid treatment was begun, glucose levels began to rise to the
200-350 range. HISS was added to the regimen and titrated to
achieve better control. He was discharged on a regimen of 24u
lantus QHS and HISS |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
iodine
Attending: ___.
Chief Complaint:
L leg pain
Major Surgical or Invasive Procedure:
ORIF L distal femur ___ plate
History of Present Illness:
Mrs. ___ is a ___ who presents s/p fall possibly
secondary to syncopal event. She presented presented to an
outside hospital, where she was found to have right knee pain.
Imaging demonstrated a left periprostethic distal femur
fracture.
She was then transferred to ___ for further management. She
has
history of bilateral knee arthroplasty performed over ___ years
ago in ___.
She was given fentanyl and dilaudid at OSH for the transfer, and
became unresponsive. She received a small dose of naloxone and
her mental status improved, however she was triggered in the ED
waiting room for altered mental status, hypotension and was
given
a subsequent dose of naloxone with good response.
Patient has history of presyncope with negative workups.
Patient presented with her family and HCP ___
(son-in-law) ___.
Patient reports left knee pain. She denies pain elsewhere. She
denies paresthesias distally.
Most of the visit was spent talking to family. Patient was
having
word finding difficulties and was confused.
Past Medical History:
-Anxiety.
-Panic attacks.
-History of thyroidectomy.
-Hypothyroidism.
-Asthma
-GERD
-Depression
-Breast Cancer
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
CV: RRR
P: unlabored breathing
GI: NTND
Left lower extremity:
- skin clean/dry/intact
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 03:36AM BLOOD WBC-5.9 RBC-3.20*# Hgb-9.5*# Hct-27.2*#
MCV-85 MCH-29.7 MCHC-34.9 RDW-16.1* RDWSD-49.9* Plt ___
___ 06:35AM BLOOD WBC-6.0 RBC-2.51* Hgb-7.2* Hct-21.2*
MCV-85 MCH-28.7 MCHC-34.0 RDW-18.0* RDWSD-55.3* Plt ___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, left knee fracture. hypotensive // please
evaluate for evidence of traumatic injury, infectious process
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, 16.3 cm; CTDIvol = 49.3 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. Gray-white matter differentiation is
preserved. Ventricles and sulci are prominent compatible with global volume
loss. Scattered periventricular and subcortical white matter hypodensities
are likely sequela of chronic small vessel disease. Basilar cisterns are
patent. Atherosclerotic calcifications noted in the intracranial ICAs
bilaterally.
Included paranasal sinuses and mastoids are essentially clear noting mild
mucosal thickening in the ethmoid air cells and partially opacified mastoid
tips bilaterally. Skull and extracranial soft tissues are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ woman presenting after fall. Evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed through the
cervical spine. Soft tissue and bone algorithm images were generated. Coronal
and sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 760 mGy-cm.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
No definite evidence of acute cervical spine fracture. Multilevel
degenerative changes of the cervical spine are extensive. The left curvature
of the cervical spine is moderate. Anterolisthesis of C3 on C4 is moderate,
likely degenerative. Anterolisthesis of C4 on C5 is mild. Anterolisthesis of
C7 on T1 is mild. Degenerative changes are most pronounced C3-C4 and C5-C6
with significant loss of intervertebral disc height, endplate sclerosis,
subchondral cysts, and anterior posterior osteophytes. There is also moderate
facet joint hypertrophy.
A disc bulge and posterior osteophytes at C5-C6 indents the anterior spinal
canal and probably cause narrowing, incompletely evaluated on this exam.
Right neural foraminal narrowing at C3-C4 is severe. Other levels of neural
foraminal narrowing throughout the cervical spine are less pronounced.
Expansion of the C5 and C6 right transverse foramina (series 602b, image 29;
series 2, image 47, 44) and C6-C7 right neural foramina is thought to be
secondary to a chronic process given appearance of the bone. The differential
includes nerve sheath tumor, although the location is atypical, and less
likely, vascular abnormality such as aneurysm which cannot be excluded.
No prevertebral soft tissue swelling. The bones are diffusely demineralized.
Atherosclerotic calcifications noted at the carotid bulbs bilaterally.
IMPRESSION:
1. No definite evidence for acute cervical spine fracture.
2. Severe multi-level degenerative changes as above, most pronounced at C3-C4
and C5-C6 with multiple levels of spondylolisthesis that are thought to be
degenerative.
3. Spinal canal narrowing at C5-C6 from disc bulge and posterior osteophytes.
4. Severe C3-C4 right neural foraminal narrowing.
5. Expansion of the right C5-C6 transverse foramen now C6-C7 right neural
foramina appears chronic for which the etiology includes nerve sheath tumor,
with atypical location, and less likely a vascular abnormality such as
aneurysm. As clinically indicated, further evaluation with MRI could be
performed.
RECOMMENDATION(S): 1. If there is clinical concern for ligamentous injury or
neurologic symptoms suggesting spinal cord, MRI could be performed to further
evaluate.
2. As clinically indicated, further evaluation with MRI could be performed to
evaluate for nerve sheath tumor and/or vertebral artery abnormality/aneurysm
as above.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman presenting after fall with left knee fracture,
now hypotensive. Evaluate for traumatic injury or infectious process. NO_PO
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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total exam DLP: 1451.77 mGy-cm
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
LOWER CHEST: Bilateral trace pleural effusions are nonhemorrhagic. Adjacent
relaxation atelectasis is minimal. Parenchymal opacity the lingula is likely
atelectasis. The heart is markedly enlarged. No evidence of a pericardial
effusion. Calcified and noncalcified atherosclerotic disease in the partially
imaged lower thoracic aorta is moderate. A paraesophageal hiatal hernia is
small (series 2, image 21). No evidence of fracture in the partially imaged
lower chest cage.
ABDOMEN:
HEPATOBILIARY: Tiny liver are too small to accurately characterize CT, likely
cysts or biliary hamartomas (series 6, image 66, 73). No intrahepatic or
extrahepatic biliary ductal dilation. The gallbladder is unremarkable. No
ascites.
PANCREAS: A 5 mm hypodensity in the pancreatic tail (series 2, image 40) and 7
mm hypodensities in the pancreatic body are likely side-branch IPMNs (series
2, image 47). No main pancreatic ductal dilation. No peripancreatic fat
stranding or fluid collection. No pancreatic calcifications.
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 are numerous bilateral renal cortical and peripelvic cysts.
Pelvicaliectasis of right kidney is mild. The right ureter is normal caliber.
There is moderate to severe left hydronephrosis, likely from chronic UPJ
obstruction. Left ureter is not dilated. No perinephric abnormality.
GASTROINTESTINAL: A hiatal hernia is small. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. No bowel obstruction, free air, or
intra-abdominal fluid collection. No evidence of mesenteric injury.
No retroperitoneal hematoma.
PELVIS: The urinary bladder is moderately distended and unremarkable. The
distal ureters are unremarkable. No free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal masses.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Extensive calcified and noncalcified
atherosclerotic disease is noted. Calcified and noncalcified atherosclerosis
at the origin of the celiac trunk and SMA is at least moderate to severe. The
celiac axis demonstrates moderate to severe narrowing at the origin. The SMA
is only mildly narrowed at the origin. The splenic vein is attenuated but
patent (series 6, image 45). The main portal vein and SMV are patent.
Atherosclerotic calcifications at the bilateral renal ostium is at least
mild-to-moderate with only mild bilateral narrowing. Accessory left renal
artery is also noted. There is an incidental retroaortic left renal vein
(series 5, image 59). The origin of the ___ is attenuated but patent (series
6, image 57).
BONES: No evidence of acute fracture in the abdomen or pelvis. Multi-level
degenerative changes of lumbosacral spine are extensive. Degenerative changes
in both hips are moderate.
SOFT TISSUES: No soft tissue hematoma in the abdomen or pelvis.
PROXIMAL LOWER EXTREMITIES:
There bilateral knee replacements. Streak artifact from the bilateral knee
replacements limits detailed evaluation of adjacent structures. Within
limitation:
There is a comminuted, angulated, and displaced closed fracture of the left
diaphysis extending into the metaphysis just proximal to the joint
replacement. No definite evidence of fracture of the hardware. There is a is
moderate to small left lipohemarthrosis with a layering hematocrit (series 2,
image 277; series 303, image 29). No soft tissue gas.
Evaluation is limited by streak artifact but cortical irregularity of the left
patella suggests a mildly displaced fracture versus streak artifact ___,
image 40). There is a left knee joint dislocation with internal rotation of
the distal left femur fracture fragment and left patella medially.
No evidence of active extravasation or pseudoaneurysm. Asymmetric enlargement
of left proximal thigh extensor and flexor muscles is consistent with
intramuscular edema and hematoma.
There is a 3 x 1.9 x 3.9 cm hematoma along the lateral left proximal femur
(series 2, image 255; series 303, image 32). Additional discrete hematoma
measures 3.9 x 1.9 x 3 cm.
Calcified and noncalcified atherosclerosis of the bilateral femoral arteries
are mild-to-moderate. Atherosclerotic calcified and noncalcified plaque in the
bilateral popliteal arteries are moderate. These vessels are patent without
visualized vascular injury.
The right knee replacement appears intact.
IMPRESSION:
1. Comminuted, displaced and angulated closed fracture of the left distal
femoral diaphysis and metaphysis extending to the knee prosthesis. No
definite evidence of hardware fracture.
2. Possible mildly displaced left patellar fracture, versus artifact.
3. Moderate intramuscular hematoma and edema in the left thigh and 2 small
soft tissue hematomas in the distal left thigh measuring 3.2 x 3.2 cm and 3.9
x 1.9 x 3 cm, respectively. No evidence of pseudoaneurysm or active
extravasation.
4. No evidence of traumatic injury in the partially imaged lower chest or
abdomen and pelvis.
5. Extensive diffuse atherosclerosis with probably moderate narrowing at the
origins of the celiac trunk, SMA, and ___ as above.
6. Moderate to severe left hydronephrosis, suggesting chronic UPJ obstruction.
Mild right pelvicaliectasis.
7. Several pancreatic hypodensities measuring up to 7 mm, likely side-branch
IPMNs.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: LEFT FEMUR FX.ORIF
IMPRESSION:
Fluoroscopic images show placement of a fixation device at about a
periprosthetic fracture of the distal femur. The total knee arthroplasty
remains in place.
Further information can be gathered from the
Radiology Report
INDICATION: ___ with hypoxia, dyspnea. right-sided B lines // plz evaluate
for fluid overload, evidence of infectious process, aspiration
TECHNIQUE: AP supine view of the chest.
COMPARISON: Same-day CT abdomen pelvis.
FINDINGS:
Linear left basilar opacity is likely atelectasis. Elsewhere, lungs are
clear. Patient is rotated however the cardiomediastinal silhouette is grossly
within normal limits. There is tortuosity of the descending thoracic aorta.
No displaced fractures seen. Degenerative changes noted in the spine and at
the shoulders.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with left knee fracture // please evaluate for traumatic
injury
TECHNIQUE: AP view the pelvis. AP and lateral views of the proximal distal
left femur.
COMPARISON: None.
FINDINGS:
Bones are demineralized. There is an acute comminuted fracture through the
distal left femur extending to the femoral component of the left knee
arthroplasty. There is angulation and displacement of multiple fracture
fragments. More proximally, there is no femoral fracture. Moderate
degenerative changes seen at the hips bilaterally. Pubic symphysis and SI
joints are preserved. Vascular calcifications are noted.
IMPRESSION:
Acute comminuted distal left femoral periprosthetic fracture.
Radiology Report
INDICATION: ___ with left knee fracture // please evaluate for traumatic
injury
TECHNIQUE: Three views of the left knee.
COMPARISON: None.
FINDINGS:
There is a left total knee arthroplasty. There is an acute comminuted
fracture through the distal left femur extending to the femoral component of
the knee arthroplasty. Significant associated soft tissue swelling is seen as
well as a suspected suprapatellar effusion. No additional fractures
identified.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: s/p Fall, L Knee pain
Diagnosed with Oth fracture of lower end of left femur, init for clos fx, Periprosth fracture around internal prosth l hip jt, init, Fall on same level, unspecified, initial encounter
temperature: 100.4
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 117.0
dbp: 62.0
level of pain: 3
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for ORIF L
distal femur fracture, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the left lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Pleurex placement ___
History of Present Illness:
Mr. ___ is a ___ male w/ PMH EtOH cirrhosis (MELD
35)
complicated by esophageal varices/portal gastropathy/GAVE,
hepatic encephalopathy with medication non-adherence,
diuretic-refractory ascites (requiring twice weekly paracentesis
~4L), HRS, chronic renal insufficiency, who presents with
altered
mental status. He went to interventional radiology for
therapeutic paracentesis today where they noted that he was
altered. He was sent to the emergency department for further
evaluation. States that he feels more tired, but denies CP, SOB,
abd pain, hematemesis, blood in stools.
Of note, he was recently hospitalized for lethargy and abdominal
pain, found to have Raoultella SBP and bacteremia. He was
discharged on ___. He also has had multiple recent ICU
admissions for UGI bleeding, most recently from ___ for
acute blood loss anemia from portal hypertensive gastropathy.
In the ED,
- Initial Vitals: T 97.3 HR 78 BP 101/64 RR 18 SpO2 100% RA
- Exam: aa/xo1-2, +guaiac stools, abdomen distended no TTP
- Labs: WBC 3.8, Hgb 6.2, Plt 64, INR 3.3, BUN 45, Cr 2.1,
Lactate 2.1
- Imaging:
CXR: Left mid to lower lung linear opacity most likely
represents
atelectasis or scarring. No definite focal consolidation.
RUQUS: 1. Cirrhotic liver morphology with splenomegaly and
moderate ascites. 2. Patent portal vein. 3. Distended
gallbladder
with complex sludge which appears increased in size
and more heterogeneous than in prior study. A continuous
gallbladder wall is difficult to identify probably given the
complexity of its intraluminal contents however, please note
that
gangrenous cholecystitis may have similar appearance in the
appropriate clinical context.
- Consults: Hepatology
- Interventions:
Paracentesis: 5.7 L of fluid were removed, and 20 cc were sent
for analysis. Received albumin.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- Hypertension
- EtOH use disorder
- EtOH cirrhosis
- Iron deficiency anemia
Social History:
___
Family History:
Mother had breast cancer. Father died of old age.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 97.4 HR 81 BP 116/64 RR 15 SpO2 99% RA
GENERAL: Cachectic, resting in bed, appears lethargic, NAD
HEENT: NCAT. PERRL, EOMI. Sclera icteric. MMM. Black lesions on
lips.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur best heard at LLSB.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, ___ edema. Pulses
DP/Radial
2+ bilaterally.
SKIN: Warm. Petechiae on UE. No visible rashes.
NEUROLOGIC: Lethargic, oriented to person, place, and
year/season. Unable to state the month. Able to state days of
the
week. Follows command.
Discharge Physical Exam
==========================
VS: ___ 0622 RR: 18
___ Temp: 97.6 PO BP: 118/72 HR: 86 RR: 18 O2 sat: 94%
O2 delivery: RA
GENERAL: Cachectic, resting in bed, comfortable, calm
HEENT: Sclera icteric.
LUNGS: No increased work of breathing on RA.
ABDOMEN: distended
NEUROLOGIC: speech clear
Pertinent Results:
ADMISSION LABS:
===============
___ 04:15PM BLOOD WBC-3.8* RBC-2.15* Hgb-6.2* Hct-19.1*
MCV-89 MCH-28.8 MCHC-32.5 RDW-20.7* RDWSD-66.6* Plt Ct-64*
___ 04:15PM BLOOD Neuts-55.2 Lymphs-17.2* Monos-9.4
Eos-16.7* Baso-1.0 Im ___ AbsNeut-2.11 AbsLymp-0.66*
AbsMono-0.36 AbsEos-0.64* AbsBaso-0.04
___ 08:20AM BLOOD ___
___ 04:15PM BLOOD Glucose-103* UreaN-45* Creat-2.1* Na-137
K-3.7 Cl-110* HCO3-11* AnGap-15
___ 04:15PM BLOOD ALT-12 AST-41* AlkPhos-82 TotBili-5.5*
___ 04:15PM BLOOD Lipase-158*
___ 04:15PM BLOOD Albumin-3.8 Calcium-10.5* Phos-4.2 Mg-2.1
___ 02:57AM BLOOD ___ pO2-62* pCO2-29* pH-7.27*
calTCO2-14* Base XS--11
___ 04:15PM BLOOD Lactate-2.1*
Discharge Labs (Last Labs ___
=====================================
___ 10:30AM BLOOD WBC-6.0 RBC-2.80* Hgb-8.3* Hct-26.1*
MCV-93 MCH-29.6 MCHC-31.8* RDW-19.7* RDWSD-66.8* Plt Ct-36*
___ 06:15AM BLOOD ___ PTT-44.5* ___
___ 10:30AM BLOOD Glucose-139* UreaN-82* Creat-2.2* Na-149*
K-4.8 Cl-121* HCO3-17* AnGap-10
___ 06:15AM BLOOD ALT-17 AST-68* AlkPhos-284* TotBili-3.8*
___ 10:30AM BLOOD Calcium-10.2 Phos-3.9 Mg-4.4*
Other Pertinent Labs/Micro
============================
___ 05:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:25PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:25PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 05:25PM URINE CastHy-9*
___ 05:25PM URINE Mucous-RARE*
___ 01:50PM ASCITES TNC-480* RBC-8826* Polys-2* Lymphs-56*
Monos-28* Eos-1* Basos-1* Plasma-4* Macroph-5*
___ 1:50 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:57 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 04:11AM BLOOD Lactate-0.9
IMAGING RESULTS:
================
Paracentesis (___)
1. Technically successful ultrasound guided diagnostic and
therapeutic paracentesis.
2. 5.7 L of fluid were removed, and 20 cc were sent for
analysis.
CXR (___)
Left mid to lower lung linear opacity most likely represents
atelectasis or scarring. No definite focal consolidation.
Liver/Gallbladder US (___)
1. Cirrhotic liver morphology with splenomegaly and moderate
ascites.
2. Patent portal vein.
3. Distended gallbladder with complex sludge which appears
increased in size and more heterogeneous than in prior study. A
continuous gallbladder wall is difficult to confirm, probably
given the complexity of its intraluminal contents however,
please note that gangrenous cholecystitis is not excluded.
CT ABD & PELVIS WITH CONTRAST (___)
IMPRESSION:
1. There is a moderate-sized splenorenal shunt. Small
recanalized umbilical vein, patent main portal vein and its
branches, small sized varices around the distal esophagus,
stomach, mesentery and around the spleen. Rectal wall varices
are also noted.
2. Cirrhotic liver morphology with splenomegaly, large volume
ascites. No focal liver lesions concerning for HCC.
3. The gallbladder is severely distended, and remains distended
over multiple prior studies including the ultrasound from ___. The distended gallbladder is filled with sludge
and hyperdense material without associated gallbladder wall
thickening. This appearance of the gallbladder may be related
to gallbladder neck obstruction and prolonged fasting status-the
gallbladder is seen to progressively distend on multiple prior
studies with a similar appearance dating back to ___.
4. Multiple enlarged porta hepatis lymph nodes are likely
reactive. Additional incidental findings include splenic
hemangioma and a subcentimeter cyst.
CT Head wo contrast (___)
No evidence of infarction, hemorrhage or mass effect
PLEUREX DRAINAGE CATHETER PLACEMENT (___)
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
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 60 mL PO TID controlled hepatic encephalopathy
3. Midodrine 5 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. rifAXIMin 550 mg PO BID hepatic encephalopathy
7. Sucralfate 1 gm PO QID
8. Thiamine 100 mg PO DAILY
9. HydrOXYzine 10 mg PO TID:PRN Itching
10. Ciprofloxacin HCl 500 mg PO DAILY
Discharge Medications:
1. Haloperidol 1.25 mg PO BID:PRN agitation
RX *haloperidol 1 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
2. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
3. Lactulose 30 mL PO Q4H:PRN AMS
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth q4hr Disp #*1
Bottle Refills:*0
4. HydrOXYzine 10 mg PO TID:PRN Itching
RX *hydroxyzine HCl 10 mg 1 ml by mouth three times a day Disp
#*15 Tablet Refills:*0
5. rifAXIMin 550 mg PO BID hepatic encephalopathy
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute on Chronic Hepatic Encephalopathy
Decompensated Cirrhosis
Secondary Diagnosis: Ascites
Acute on chronic anemia
Acute kidney injury
Coagulopathy
Enlarged Gallbladder
Lactic Acidosis
Hypernatremia
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: Ultrasound-guided diagnostic and therapeutic paracentesis
INDICATION: ___ year old man with ascites // Therapeutic
TECHNIQUE: Ultrasound-guided diagnostic and therapeutic paracentesis
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: left lower quadrant
Fluid: 5.7 L of serosanguinous fluid
Samples: None
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.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
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:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 5.7 L of fluid were removed, and 20 cc were sent for analysis.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with altered mental status // Infectious work-up
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Left mid to lower lung platelike linear opacity most likely represents
atelectasis or scarring. No definite focal consolidation is seen. There is
no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes
are unremarkable.
IMPRESSION:
Left mid to lower lung linear opacity most likely represents atelectasis or
scarring. No definite focal consolidation.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with altered mental status, alcoholic cirrhosis //
Evaluate cirrhosis, PVT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Multiple ultrasound from ___ to the most recent
dated ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: Mildly dilated measuring up to 7 mm, similar to the prior study.
GALLBLADDER: Again demonstrated is a distended gallbladder with complex sludge
which appears increased in amount and more heterogeneous/irregular than in the
prior study, with hypoechoic and echogenic serpiginous regions. A continuous
gallbladder wall is difficult to confirm given the complexity of its
intraluminal contents.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Again demonstrated is heterogeneous hyperechoic focus measuring up to
4.6 cm, probably representing a hemangioma.
Spleen length: 18.7 cm, enlarged.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.6 cm
Left kidney: 12.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver morphology with splenomegaly and moderate ascites.
2. Patent portal vein.
3. Distended gallbladder with complex sludge which appears increased in size
and more heterogeneous than in prior study. A continuous gallbladder wall is
difficult to confirm, probably given the complexity of its intraluminal
contents however, please note that gangrenous cholecystitis is not excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: NG just placed
IMPRESSION:
Transesophageal drainage tube is curled in the upper portion of a nondistended
stomach. Lungs are clear. Heart size top-normal. No pleural abnormality.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: interval dobhoff placement // Dobhoff placement Dobhoff
placement
IMPRESSION:
Enteric tube tip is in the expected location of the stomach. Mild dilatation
of the colon is partially imaged.
Heart size and mediastinum are stable. Lungs are clear. No appreciable
pleural effusion or pneumothorax is present.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old male w/ AMS likely secondary to hepatic
encephalopathy but refractory, would like r/o bleed/infarct // R/o bleed or
infarct
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.5 mGy-cm.
Total DLP (Head) = 935 mGy-cm.
COMPARISON: CT of the head from ___.
FINDINGS:
There is no evidence of fracture, infarction,hemorrhage,edema, or mass. The
ventricles and sulci are prominent consistent with age-related involutional
change..
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal. A
nasogastric tube is partially visualized.
IMPRESSION:
1. No evidence of infarction, hemorrhage or mass effect.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with refractory hepatic encephalopathy to
multiple days of lactulose, would like CT A/P to evaluate for hepatic venous
shunt that could be contributory // eval for shunting contributing to hepatic
encephalopathy
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 not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 61.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 215.1
mGy-cm.
2) Spiral Acquisition 2.3 s, 30.7 cm; CTDIvol = 14.6 mGy (Body) DLP = 448.4
mGy-cm.
3) Spiral Acquisition 4.6 s, 60.4 cm; CTDIvol = 14.9 mGy (Body) DLP = 902.3
mGy-cm.
4) Spiral Acquisition 2.3 s, 30.7 cm; CTDIvol = 14.6 mGy (Body) DLP = 448.8
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
6) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 26.7 mGy (Body) DLP =
13.4 mGy-cm.
Total DLP (Body) = 2,030 mGy-cm.
COMPARISON: CT abdomen pelvis ___. CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate mild bibasilar atelectasis.
There is no evidence of pleural or pericardial effusion. There is mild
coronary artery calcifications.
ABDOMEN:
HEPATOBILIARY: The liver is shrunken and nodular in contour consistent with
known cirrhosis. No suspicious hepatic lesions meeting OPTN 5 criteria for
HCC.
There is no evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is significantly distended, measuring up to 14 x 7.7 cm and
contains sludge within it seen as hyperdense material on the noncontrast
study, better evaluated on the ultrasound dated ___. There is no
hyperemia within the liver parenchyma adjacent to the gallbladder; no
gallbladder wall thickening noted. This appearance may represent marked
dilation of the gallbladder due to prolonged fasting or obstruction of the
neck of the gallbladder by sludge.
There is large volume ascites measuring up to ___ 7 consistent with simple
ascites.
The main portal vein, splenic and superior mesenteric veins are patent.
There are multiple small periesophageal, perigastric, porta hepatis,
perisplenic varices with a small recanalized umbilical vein.
A small splenorenal shunt is seen opening into the retroaortic component of
the circumaortic left renal vein.
There are multiple rectal wall varices as well.
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 is enlarged measuring up to 17.9 cm, previously measuring
up to 17.1 cm in ___. There is a stable 3.9 x 4.6 cm partially
calcified hypodense lesion within the spleen with filling in of contrast on
the delayed phase consistent with a hemangioma (303; 75), similar to prior.
Another, smaller 8 mm splenic hypodensity (305:80) is likely a cyst.
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 solid
renal lesion. 0.3 cm hypodense lesion in the left midpole is too small to
characterize but likely represents a renal cyst (303; 100). There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: NG tube terminates within the stomach. Small bowel loops
demonstrate normal caliber and wall thickness throughout. The colon and rectum
are within normal limits.
PELVIS: The urinary bladder is markedly distended and contains small locules
of air, possibly related to recent instrumentation.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: Multiple enlarged periportal lymph nodes measure up to 2.1 cm
(305; 68). Prominent mesenteric lymph nodes measure up to 0.9 cm in short
axis (303; 0 8), but are not pathologically enlarged. There is no pelvic or
inguinal lymphadenopathy.
VASCULAR:
Hepatic arterial anatomy is conventional. There is early bifurcation of the
right renal artery. There are 2 left renal arteries. There is a circumaortic
left renal vein.
The portal vasculature, hepatic veins, SMV, and splenic veins are patent.
There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is
noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are healed fracture deformities of the right L2 transverse process in
chronically displaced fractures of the right L3 and L4 transverse processes.
SOFT TISSUES: There is a small umbilical hernia containing ascitic fluid.
IMPRESSION:
1. There is a moderate-sized splenorenal shunt. Small recanalized umbilical
vein, patent main portal vein and its branches, small sized varices around the
distal esophagus, stomach, mesentery and around the spleen. Rectal wall
varices are also noted.
2. Cirrhotic liver morphology with splenomegaly, large volume ascites. No
focal liver lesions concerning for HCC.
3. The gallbladder is severely distended, and remains distended over multiple
prior studies including the ultrasound from ___. The distended
gallbladder is filled with sludge and hyperdense material without associated
gallbladder wall thickening. This appearance of the gallbladder may be
related to gallbladder neck obstruction and prolonged fasting status-the
gallbladder is seen to progressively distend on multiple prior studies with a
similar appearance dating back to ___.
4. Multiple enlarged porta hepatis lymph nodes are likely reactive.
Additional incidental findings include splenic hemangioma and a subcentimeter
cyst.
NOTIFICATION:
The findings were discussed with ___, m.D. by ___, M.D. on
the telephone on ___ at 4:49 pm, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ male w/ PMH EtOH cirrhosis (MELD 35) complicated by
esophageal varices/portal gastropathy/GAVE, hepatic encephalopathy,
diuretic-refractory ascites (requiring twice weekly large-volume
paracentesis), HRS, chronic renal insufficiency, who presented with
decompensated cirrhosis and hepatic encephalopathy, now CMO. Requesting
pleurex catheter be placed to relieve discomfort related to refractory
ascites. // pleurex placement for ascites
COMPARISON: CT of the abdomen and pelvis from ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ fellow performed the procedure. The
attending(s) 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 not used for the procedure. 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: ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 0.4 minutes, 3 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 5 ___ catheter was advanced into the ascitic fluid.
An Amplatz 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 site was closed with ___
Polysyn subcuticular suture and Steri-Strips. Sterile dressings were applied.
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
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Lethargy
Diagnosed with Other fatigue
temperature: 97.3
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 101.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | SUMMARY
====================
___ male w/ ___ EtOH cirrhosis (MELD 35) complicated by
esophageal varices/portal gastropathy/GAVE, hepatic
encephalopathy, diuretic-refractory ascites (requiring twice
weekly large-volume paracentesis), HRS, chronic renal
insufficiency, who presented with ascites and hepatic
encephalopathy likely precipitated by medication non-compliance,
found to have splenorenal shunt on CTAP. Transitioned to CMO
while inpatient and had a pleurex placed for ascetic drainge. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubated on ___, Extubated to Bipap on ___
History of Present Illness:
___ h/o missed MI (no intervention, ___, demand NSTEMI (___),
COPD, rectal cancer s/p chemoradiation and LAR, synchronous
breast cancer s/p lumpectomy, p/w dyspnea
Per the pt's son, prior to admission, the patient had frequent
non-productive cough and had caught a cold that was going around
the home. She had some R sided abdominal pain, but otherwise did
not complain of any symptoms. She did not mention chest pain or
palpitations, but per the son, would be unlikely to volunteer
that information. The son also noted that she had some leg
swelling, which has since resolved. She was satting 89% at home
up until the son returned home and found her in the bathroom
satting in the ___. She was taken to ___ for preliminary
work up and then transferred to ___.
In the ED, she was noted to have wide complex tachycardia to the
200's and she received amiodarone 150mg IV, and reverted to
sinus.
In the ED,
- Initial vitals were: HR 116, BP 116/83, RR 30, 93% NIV. Tmax
100.8
- Labs notable for: WBC 16.4, Na 133, Cr 1.5. Initial VBG 7.14,
CO2 93. Repeat 7.30, CO2 49 intubated.
- Studies notable for:
CXR:
1. Standard positioning of the endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion and small right pleural
effusion.
3. Patchy opacification in the right mid lung field may reflect
pneumonia.
- Patient was given:
Lasix 40 IV
Zosyn
Amiodarone 150mg IV, started on drip at 1
Of note, the patient has had frequent ___
hospitalizations
for COPD exacerbation. She does not use any nebs or home O2. Her
medication compliance at home is reportedly rather poor.
On arrival to the CCU, the patient is intubated and sedated. She
had a brief run of tachycardia to the 150's, which self
resolved.
Full review of systems cannot be obtained due to mental status
and intubation
Past Medical History:
- Breast Cancer Stage I ER/PR positive HER2 negative (hormonal
therapy) s/p L needle localized ___
- Rectal Cancer Stage IIIB(neoadjuvant chemo and radiation
completed (___). Planned for ileostomy takedown soon.
- CAD s/p MI
- HTN
- HLD
- COPD
- Alcohol use (2 drinks per day)
- Sialadenitis
- Hemorrhoids
Social History:
___
Family History:
- mother died of lung cancer
- father had prostate cancer but died of MI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: HR 95, BP 130/65, RR 25, saO2 100% Intubation
GENERAL: Intubated, sedated, lying in bed
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL.
NECK: Supple. JVP difficult to assess.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-distended. No palpable hepatomegaly or
splenomegaly. Ileostomy bag in place with gas.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: ___, intubated, sedated. not responding to commands.
DISCHARGE PHYSICAL EXAM
GENERAL: Elderly appearing woman in no acute distress.
Comfortable, non-toxic.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
PULMONARY: CTAB. Breathing comfortably on room air.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, non-edematous.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
___ 01:59PM BLOOD WBC-16.4* RBC-4.50 Hgb-13.5 Hct-42.1
MCV-94 MCH-30.0 MCHC-32.1 RDW-17.8* RDWSD-61.4* Plt ___
___ 01:59PM BLOOD Neuts-90.1* Lymphs-1.5* Monos-6.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-14.82* AbsLymp-0.25*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.03
___ 01:59PM BLOOD ___ PTT-25.8 ___
___ 01:59PM BLOOD Glucose-198* UreaN-33* Creat-1.5* Na-133*
K-4.4 Cl-91* HCO3-26 AnGap-16
___ 01:59PM BLOOD ___
___ 01:59PM BLOOD cTropnT-0.13*
___ 05:49PM BLOOD CK-MB-3 cTropnT-0.11*
___ 05:49PM BLOOD TotProt-6.8 Calcium-9.9 Phos-3.3 Mg-1.7
Iron-20*
___ 05:49PM BLOOD calTIBC-339 Ferritn-76 TRF-261
___ 05:49PM BLOOD TSH-1.6
___ 05:49PM BLOOD PEP-NO SPECIFI IgG-1034 IgA-191 IgM-69
IFE-NO MONOCLO
___ 02:07PM BLOOD ___ pO2-46* pCO2-93* pH-7.12*
calTCO2-32* Base XS--2
___ 03:03PM BLOOD Type-ART ___ Tidal V-350 FiO2-40
pO2-116* pCO2-49* pH-7.30* calTCO2-25 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED Comment-ETT
___ 02:07PM BLOOD Lactate-2.1*
___ 02:07PM BLOOD O2 Sat-66
MICRO
-----
___ 11:22 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 5:46 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:03 pm Rapid Respiratory Viral Screen & Culture
Source: Nasal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 2:03 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:39 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
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 CLUSTERS.
Reported to and read back by ___ 19:39 X ___
___.
__________________________________________________________
___ 1:59 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:59 pm URINE CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=======
TTE ___
The left atrial volume index is normal. No thrombus/mass is seen
in the body of the left atrium (best excluded by TEE) There is
no evidence for an atrial septal defect by 2D/color Doppler. The
right atrial pressure could
not be estimated. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is SEVERE global
left ventricular hypokinesis and relative preservation of apical
and basal inferolateral systolic function. No thrombus or mass
is seen in the left ventricle. Quantitative biplane left
ventricular ejection fraction is 23 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). No ventricular septal defect is
seen. Normal right ventricular cavity size with moderate global
free wall hypokinesis. Tricuspid annular plane systolic
excursion (TAPSE) is depressed. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. There is a normal descending aorta diameter. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and severe
global hypokinesis consistent with diffuse process. Normal right
ventricular size with free wall hypokinesis. Mild mitral
regurgitation. Compared with the prior TTE ___ , the
biventricular systolic function is now less vigorous.
DISCHARGE LABS
===============
___ 05:20AM BLOOD WBC-10.7* RBC-3.93 Hgb-11.5 Hct-35.3
MCV-90 MCH-29.3 MCHC-32.6 RDW-18.4* RDWSD-60.5* Plt ___
___ 05:20AM BLOOD Neuts-82* Bands-2 Lymphs-9* Monos-4*
Eos-1 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-8.99*
AbsLymp-0.96* AbsMono-0.43 AbsEos-0.11 AbsBaso-0.00*
___ 05:20AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:20AM BLOOD Glucose-81 UreaN-39* Creat-1.2* Na-136
K-5.1 Cl-98 HCO3-26 AnGap-12
___ 05:20AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Anastrozole 1 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
RX *albuterol sulfate [Ventolin HFA] 90 mcg ___ PUFF INH q4 hrs
Disp #*1 Inhaler Refills:*0
2. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
PUFF INH twice a day Disp #*1 Disk Refills:*0
5. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply patch to arm q24 hrs Disp #*28
Patch Refills:*0
6. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH daily Disp #*1 Capsule Refills:*0
7. Anastrozole 1 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
HYPERCARBIC HYPOXIC RESPIRATORY FAILURE
COMMUNITY ACQUIRED PNEUMONIA
COPD EXACERBATION
CHF EXACERBATION
WIDE COMPLEX TACHYCARDIA
ACUTE KIDNEY INJURY
TYPE 2 NSTEMI
SECONDARY DIAGNOSIS
===================
CORONARY ARTERY DISEASE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with intubation// ?ETT placement
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Endotracheal tube terminates approximately 5.5 cm from the carina. Enteric
tube courses into the stomach with tip off of the inferior borders of the
film. Heart size is borderline enlarged. Minimal atherosclerotic
calcifications are seen at the aortic arch. Mediastinal and hilar contours
are unremarkable. Mild pulmonary vascular engorgement is present. Ill-defined
patchy opacification is seen in the right midlung field, concerning for
pneumonia. A small right pleural effusion is likely present. No
pneumothorax.
IMPRESSION:
1. Standard positioning of the endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion and small right pleural effusion.
3. Patchy opacification in the right mid lung field may reflect pneumonia.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with intubation// ?interval change
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs in CTs, most recently ___.
FINDINGS:
Unchanged position of ET esophageal feeding tubes.
No pleural effusions or pneumothorax.
Heart size is top normal.
Cardiomediastinal silhouette is unremarkable.
Mild vascular congestion with mild pulmonary edema.
IMPRESSION:
No interval change compared to prior study, showing mild vascular congestion
and pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with COPD, respiratory failure, intubated with
increased pressures.// Please assess for ETT placement.
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with stable interstitial prominence. Cardiomediastinal
silhouette is stable. There is no pleural effusion. No pneumothorax is seen.
The ET and NG tube are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD exacerbation and intubated// interval
change interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Pulmonary edema present on ___ has resolved. Heart size is now
normal. Only a small region of consolidation may be present in the lingula,
or this could be the left nipple. There are no other findings to suggest
pneumonia. No pleural abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Respiratory distress
Diagnosed with Heart failure, unspecified
temperature: nan
heartrate: 116.0
resprate: 30.0
o2sat: 93.0
sbp: 116.0
dbp: 83.0
level of pain: UTA
level of acuity: 1.0 | ___ woman with a history of CAD with prior missed MI
___, no intervention), COPD, rectal cancer s/p chemoradiation
and low anterior resection, and breast cancer s/p lumpectomy who
was initially admitted to the CCU for multifactorial respiratory
failure requiring intubation in setting of acute pulmonary
edema, pneumonia, and COPD. Course further notable for new
wide-complex tachycardia, most likely to be atrial fibrillation
with aberrancy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Neurontin / local anesthesia
Attending: ___.
Chief Complaint:
right neck cellulitis and seroma
Major Surgical or Invasive Procedure:
1. Needle drainage of right neck seroma at bedside
2. placement of two ___ drains into seroma via prior neck
incision
History of Present Illness:
___ M with a history of
esophageal cancer who underwent right modified radical neck
dissection with Dr. ___ on ___ for ___ metastatic to
the neck presents with erythema and fluid collection overlying
his neck wound. He was seen in follow-up on ___ and a seroma
was noted and 55ml of clear fluid was drained. At that time
there
was no sign of infection, and the patient was started on keflex.
Over the past two days the patient notes increasing erythema and
warmth overlying the right neck incision. He reports mild
discomfort over the area, but denies fever, chills, shortness of
breath, wheeze, stridor, dysphagia, odynophagia, and chest pain.
Past Medical History:
1. Esophageal cancer as above.
2. Hypertension.
3. Atrial fibrillation.
4. GERD.
5. ___ gastrectomy.
6. Back pain, which he notes is chronic.
7. Two hernia operations.
8. Two hemorrhoid operations.
9. Direct laryngoscopy with biopsy
Social History:
___
Family History:
None listed
Physical Exam:
At time of discharge:
AF VSS
NAD
Breathing easily
right neck with drains removed
neck flat, firm, mild resolving erythema w/ skin flaking
no seroma or mass
CN 7,11,12 in tact
Pertinent Results:
___ 07:22PM BLOOD WBC-5.4 RBC-4.09* Hgb-10.4* Hct-33.6*
MCV-82 MCH-25.3* MCHC-30.8* RDW-17.1* Plt ___
___ 07:05AM BLOOD WBC-6.2 RBC-4.04* Hgb-10.1* Hct-33.0*
MCV-82 MCH-25.1* MCHC-30.7* RDW-16.7* Plt ___
___ 07:05AM BLOOD WBC-5.0 RBC-3.93* Hgb-9.9* Hct-31.7*
MCV-81* MCH-25.1* MCHC-31.1 RDW-17.4* Plt ___
Medications on Admission:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze, SOB
2. Amiodarone 200 mg PO TID
3. Amlodipine 5 mg PO DAILY
hold for BP<100
4. Aspirin 325 mg PO DAILY
5. Dabigatran Etexilate 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
hold for HR<55, BP<100
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
hold for oversedation, RR<12
9. Pantoprazole 40 mg PO Q12H
Keflex
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze, SOB
2. Amiodarone 200 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
hold for BP<100
4. Aspirin 325 mg PO DAILY
5. Dabigatran Etexilate 150 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, BP<100
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
hold for oversedation, RR<12
9. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
wound seroma
cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with a history of right neck lymph node
dissection on ___ who presents now with new redness in the
right aspect of the neck. Evaluate for evidence of abscess or any other fluid
collection.
COMPARISON: ___. Torso CT from ___.
TECHNIQUE: MDCT axial images were acquired through cervical spine after the
administration of IV contrast. Coronal and sagittal reformations were
generated.
FINDINGS: The patient is status post multilevel nodal resection in the right
neck with resection of the submandibular gland as well. In the right aspect of
the neck there is a fluid collection running anterior to the
sternocleidomastoid with mild rim enhancement with an attenuation of 17
Hounsfield units extending from the submandibular region to the anterior
aspect of the thyroid gland, without extension into the mediastinum. The
fluid collection measures 4.6 x 2.7 x 5.2 cm (AP, TR, CC ___ (4:56 and
301:44). There is some stranding in the skin adjacent to this area, likely
postoperative.
The included intracranial contents are grossly unremarkable. The visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear. The
thyroid gland is unremarkable. The patient is status post esophagectomy with
gastric pull-up, with a significant amount of debris seen within the
neoesophagus. There is a severe emphysematous disease in the lung apicies,
with a 1.3 cm linear irregular opacity in the right apex, unchanged from ___
and likely scarring. Stable severe degenerative changes of the cervical spine
and atherosclerotic calcifications of the carotid siphons.
IMPRESSION:
1. Organized fluid collection along the right aspect of the neck as described
above. Although compatible with a post-surgical seroma, possibility of
infection cannot be excluded and clinical correlation is recommended.
2. Post-esophagectomy changes with debris seen within the neoesophagus.
3. Stable chronic conditions including moderate centrilobular emphysema,
right apical nodule and severe degenerative changes of the cervical spine.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: WOUND CHECK
Diagnosed with INFECTED POST-OP SEROMA, ABN REACT-SURG PROC NEC, SECONDARY MALIG NEO NEC, HX-ESOPHAGEAL MALIGNANCY, HYPERTENSION NOS
temperature: 98.0
heartrate: 73.0
resprate: 18.0
o2sat: 99.0
sbp: 160.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted to the Otolaryngology-Head and Neck
Surgery Service on ___ellulitis and seroma
following needle drainage in the ED. He was started on IV
Vancomycin. On POD #1 the seroma reaccumulated, and a ___
drain was placed into the seroma with a pressure dressing. On
___ a second right supraclavicular seroma developed and was
drained with a second ___ drain. The patient remained
afebrile with a normal WBC. The output from the ___ drains
decreased and they were removed when appropriate. On ___ the
patient was switched from Vancomycin to doxycycline since he had
a history of MRSA that was sensitive to this antibiotics. He was
subsequently evaluated by the Infectious Disease service who
recommended ___ days of bactrim/augmentin for antibiotic
coverage.
From a cardiovascular standpoint the patient was closely
monitored on telemetry and went into atrial fibrillation with
RVR several times. He was given metoprolol IV and po to control
his rate. The cardiology service was consulted and recommended
increasing his metoprolol to 50mg daily and decreasing
amiodarone to once daily. The patient refused to take his
Pradaxa during this hospitalization, although he did agree to
take aspirin.
He continued to improve and had no reaccumulation of the seroma.
He was evaluated by nutrition who felt he could benefit from
supplementation at home. His pain was controlled on oral
medications and he was voiding independently.
He was discharged home on ___ Pt was given detailed discharge
instructions outlining wound care, activity, diet, follow-up and
the appropriate medication scripts. He will follow-up in clinic
with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ___. drainage catheter into right lower abdominal
collection
History of Present Illness:
___ female with history of RA p/t ER with 5 days of RLQ pain.
She initially
thought it was related to constipation and took MOM without
improvement ___ the pain. No N/V. Yesterday she had some
subjective fevers for which she went to her PCP today, who sent
her to the ER @ ___. A CT performed there revealed
perforated appendicitis with a 5cm abscess. She was transferred
here for further management. She denies any dysuria/hematuria
Past Medical History:
Rheumatoid arthritis, HTN
Social History:
___
Family History:
non-contributory
Physical Exam:
PE: ___ upon admission:
Vitals:98.2 102 121/75 16 95% RA
Gen: NAD
CV: RRR
Abd: S, TTP RLQ
Ext: no c/c/e
Physical examination upon discharge: ___
vital signs: t=98.0, hr=87, bp=129/57, rr=16, oxygen sat=99%
General; NAD
CV: ns1, s2,-s3, -s4
LUNGS: clear, dimished right lateral
ABDOMEN: soft, RLQ tenderness, no rebound, no guarding, ___
drain with thick pink colored drainage
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriente x 3
Pertinent Results:
___ 06:33AM BLOOD WBC-7.9 RBC-3.46* Hgb-10.4* Hct-32.4*
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.0 Plt ___
___ 08:15PM BLOOD WBC-11.2* RBC-3.76* Hgb-11.2* Hct-34.6*
MCV-92 MCH-29.9 MCHC-32.5 RDW-12.6 Plt ___
___ 09:40PM BLOOD WBC-10.3 RBC-3.93* Hgb-11.8* Hct-35.9*
MCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 Plt ___
___ 09:40PM BLOOD Neuts-90.2* Lymphs-5.3* Monos-3.6 Eos-0.5
Baso-0.4
___ 06:33AM BLOOD Plt ___
___ 09:40PM BLOOD ___ PTT-26.3 ___
___ 08:15PM BLOOD Glucose-175* UreaN-30* Creat-0.8 Na-141
K-3.3 Cl-106 HCO3-25 AnGap-13
___ 08:15PM BLOOD Calcium-8.6 Phos-1.9* Mg-2.2
___: CT interventional:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
___ 3:15 pm ABSCESS PERF FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
:Motrin, lisinopril/hctz ___, Humira
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
hold for loose stool
4. Ciprofloxacin HCl 500 mg PO Q12H
last dose ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*26 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last dose ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*39 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Sodium Chloride 0.9% Flush ___ mL IV Q8H
please flush JP drain
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % ___ cc
via ___ drain every eight (8) hours Disp #*30 Syringe Refills:*0
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
may cause dizziness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
perforated appendix
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT-guided drainage of a right lower quadrant collection.
INDICATION: ___ year old woman with ruptured appy // drain placement
COMPARISON: Reference CT from ___
PROCEDURE: CT-guided drainage of a right lower quadrant collection.
OPERATORS: Dr. ___ trainee and Dr. ___ radiologist,
who was present and supervising throughout the total procedure time.
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 supine on the CT scan table. A limited preprocedure
CTscan was performed to localize the collection. Based on the CT findings an
appropriate skin entry site for the drain placement was chosen. The site was
marked. Local anesthesia was administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A 0.038 ___ wire was placed through the
needle and needle was removed. An ___ pigtail catheter was placed into
the collection. The stiffener and wire were removed. The pigtail was
deployed. The position of the pigtail was confirmed within the collection via
CT fluoroscopy.
Approximately 10 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 a JP suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 434 mGy-cm
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of
23 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
A multiloculated right lower collection was identified as the target area.
This collection is filled with gas and fluid.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, RUPTURED APPY
Diagnosed with AC APPEND W PERITONITIS
temperature: 99.2
heartrate: 105.0
resprate: 18.0
o2sat: 93.0
sbp: 134.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | The patient was admitted to the hospital with 5 days of right
lower quadrant pain. She followed up with her primary care
provider where she was sent for a cat scan. On cat scan imaging
she was found to have perforated appendicitis with a 5cm
abscess. She was transferred here for further management. Upon
admission, the patient was made NPO and arrangements made for ___
drainage. The patient was started on a course of ciprofloxacin
and flagyl. On HD #1, the patient was taken to Interventional
Radiology where an ___ Fr. catheter was placed into the abdominal
abscess. Approximately 10 cc of purulent fluid was aspirated
with a sample sent for
microbiology evaluation.
The patient resumed a regular diet after the procedure. Her
vital signs remained stable with a white blood cell count of 8.
She was voiding and ambulating without difficulty. On HD #2, the
patient was discharged home with ___ services to assist with the
care of the drain. The patient was instructed to complete a 14
day of antibiotics. A follow-up visit was scheduled with Dr.
___ ___ 1 week. Instructions ___ care of the drain were
reviewed with the patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
TEE/DCCV x2 on ___ and ___
History of Present Illness:
___ with several days of diarrhea, nausea/vomiting and one day
of palpitations and dyspnea. Presented to urgent care where EKG
showed AF w/RVR, CXR showing pulmonary edema. She was
transferred to the ED where she received IV and PO diltiazem
with rate control, HRs 150s down to ___, and Lasix with
significant improvement in dyspnea.
Past Medical History:
- Atrial fibrillation
- HTN
- Hyperlipidemia
- Osteoarthritis
- Oseoporsis
- GERD
- Asthma
- B12 Deficiency
- Lichen Sclerosis
- Insomnia
- Atrial fibrillation
- HTN
- Hyperlipidemia
- Osteoarthritis
- Oseoporsis
- GERD
- Asthma
- B12 Deficiency
- Lichen Sclerosis
- Insomnia
Social History:
___
Family History:
mother with "heart problems"
Physical Exam:
===============
ADMISSION EXAM
===============
Physical Exam: BP 126/83, HR 103, O2 95-100% RA
Gen: Alert, oriented x3, appeared uncomfortable on initial eval
in stretcher in ED, visibly SOB; after Lasix dose patient
appears significantly more comfortable with NO visible work of
breathing
Neuro: Oriented x 3, moving all extremities
Neck/JVD: +elevated
CV: Irregular rhythm
Chest: +Bilateral rales/rhonchi, visibly SOB, improving with
diuresis
ABD: Soft, non-tender, +BS
Extr: ___ pitting edema BLE to knees, lower extremities warm
Skin: Warm/dry/intact
===============
DISCHARGE EXAM
===============
VS: Afebrile (Tcurr 97.3F), bp 105-152/ 70-95, bpcurr 105/70, HR
95-120, RR ___, 88-95% O2sat, currently on 2L O2NC
WT: 69kg- bed scale (71.3kg- stand scale on ___
Tele: Afib, few single PVCs
GENERAL: Sleeping, resting comfortably in bed
HEENT: NC/AT, MMM
NECK: Supple, no cervical lymphadenopathy
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Pan-systolic murmur ___ best heard in
the apex. No thrills, lifts. No S3 or S4.
LUNGS: CTAB, no wheezes or crackles
ABDOMEN: Soft, non-distended, +BS, non-tender to palpation in
all four quadrants
EXTREMITIES: Warm, no edema, 2+ peripheral pulses
SKIN: No lesions or rashes
PULSES: Symmetric, preserved
Pertinent Results:
===============
ADMISSION LABS
===============
___ 08:50PM BLOOD WBC-6.3 RBC-3.90 Hgb-12.2 Hct-37.3 MCV-96
MCH-31.3 MCHC-32.7 RDW-15.3 RDWSD-52.5* Plt ___
___ 08:50PM BLOOD Neuts-72.1* Lymphs-15.6* Monos-10.0
Eos-1.4 Baso-0.6 Im ___ AbsNeut-4.53 AbsLymp-0.98*
AbsMono-0.63 AbsEos-0.09 AbsBaso-0.04
___ 09:22PM BLOOD ___ PTT-35.2 ___
___ 08:50PM BLOOD Glucose-122* UreaN-32* Creat-1.2* Na-140
K-4.2 Cl-104 HCO3-24 AnGap-16
___ 06:13AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
==================
PERTINENT RESULTS
==================
LABS
==================
___ 08:50PM BLOOD proBNP-4812*
___ 09:22PM BLOOD cTropnT-<0.01
___ 06:13AM BLOOD proBNP-4150*
___ 09:18AM BLOOD CK-MB-5 cTropnT-<0.01
---
___ 07:05AM BLOOD ALT-28 AST-26 LD(LDH)-215 AlkPhos-105
TotBili-1.7* DirBili-0.3 IndBili-1.4
---
___ 06:13AM BLOOD TSH-5.2*
___ 07:05AM BLOOD T4-6.8
===============
MICROBIOLOGY
===============
___ 9:26 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
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
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 12:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:11 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
==============
IMAGING
==============
CXR (___): In comparison with the study of ___, the
patient has taken a better inspiration. Again there is mild
enlargement of the cardiac silhouette with elevation of
pulmonary venous pressure in bilateral pleural effusions with
compressive basilar atelectasis.
---
CT head without contrast (___):
The study is limited by motion artifact, decreasing sensitivity
for early infarction. Within this limitation, there is no
evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of
involutional changes. There are periventricular and subcortical
hypodensities, which may represent small vessel ischemic
changes.
There is no evidence of fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION: 1. No acute intracranial pathology.
---
CXR (___): In comparison with the study of ___, the
patient has taken a better inspiration. Continued enlargement of
the cardiac silhouette with elevation of pulmonary venous
pressure. The hemidiaphragms are more sharply seen on both
sides. This could represent improved pleural effusions and
compressive atelectasis, though it could merely be a
manifestation of a more upright position of the patient.
---
Abdominal radiography (___):
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no
gross pneumoperitoneum. Osseous structures are notable for
moderate degenerative disease of the lumbar spine. There are no
unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION: No radiographic evidence of obstruction.
---
TTE (___):
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mildly dilated right ventricle. Normal global and
regional biventricular systolic function. Mild aortic stenosis.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
===============
DISCHARGE LABS
===============
___ 05:45AM BLOOD Glucose-87 UreaN-34* Creat-1.1 Na-141
K-4.4 Cl-103 HCO3-24 AnGap-18
___ 05:45AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.2
___ 04:35AM BLOOD WBC-9.0 RBC-3.99 Hgb-12.2 Hct-38.3 MCV-96
MCH-30.6 MCHC-31.9* RDW-15.0 RDWSD-52.8* Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Ranitidine 300 mg PO DAILY:PRN heartburn
4. Simvastatin 40 mg PO QPM
5. Cyanocobalamin 1000 mcg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
8. Calcium Carbonate 1500 mg PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Ciprofloxacin HCl 500 mg PO Q24H UTI Duration: 3 Days
4. Docusate Sodium 100 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Apixaban 5 mg PO BID
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Calcium Carbonate 1500 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. PreserVision Lutein (vit C-vit E-copper-zinc-lutein) 226
mg-200 unit -5 mg-0.8 mg oral BID
12. Ranitidine 300 mg PO DAILY:PRN heartburn
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Atrial fibrillation
Secondary diagnosis: Acute on chronic diastolic heart failure,
Urinary tract infection, Altered mental status
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: ___ year old woman with shortness of breath, hypoxemia //
Pulmonary edema? Pulmonary edema?
IMPRESSION:
In comparison with the study of ___, the patient has taken a better
inspiration. Again there is mild enlargement of the cardiac silhouette with
elevation of pulmonary venous pressure in bilateral pleural effusions with
compressive basilar atelectasis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with afib with rvr and h/o dementia with word
finding difficulties and left pupil non-responsive to light. // Evaluate for
intracranial bleed or stroke.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 1.8 s, 6.4 cm; CTDIvol = 49.8 mGy (Head) DLP =
318.0 mGy-cm.
2) Sequenced Acquisition 3.0 s, 10.6 cm; CTDIvol = 49.8 mGy (Head) DLP =
530.0 mGy-cm.
3) Sequenced Acquisition 1.2 s, 4.3 cm; CTDIvol = 49.8 mGy (Head) DLP =
212.0 mGy-cm.
Total DLP (Head) = 1,060 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is limited by motion artifact, decreasing sensitivity for early
infarction. Within this limitation, there is no evidence of infarction,
hemorrhage, edema, or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. There are periventricular and subcortical
hypodensities, which may represent small vessel ischemic changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial pathology.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS and Afib w/RVR, evaluating for
infectious process // r/o pneumonia, pulmonary edema r/o pneumonia,
pulmonary edema
IMPRESSION:
In comparison with the study of ___, the patient has taken a better
inspiration. Continued enlargement of the cardiac silhouette with elevation
of pulmonary venous pressure. The hemidiaphragms are more sharply seen on
both sides. This could represent improved pleural effusions and compressive
atelectasis, though it could merely be a manifestation of a more upright
position of the patient.
Radiology Report
INDICATION: ___ year old woman with afib rvr with changes of mental status and
nausea // Bowel obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None available.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for moderate degenerative disease of the lumbar
spine.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence of obstruction.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Palpitations
Diagnosed with Unspecified atrial fibrillation
temperature: 98.6
heartrate: 155.0
resprate: 18.0
o2sat: 99.0
sbp: 156.0
dbp: 104.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ y/o woman with a history of HTN, HLD, and
atrial fibrillation on Eliquis who presented with increasing
dyspnea and bilateral ___ edema and was found to be in atrial
fibrillation with ventricular rates initially in the 140s-150s.
Patient is s/p TEE/DCCV x2 on ___ and ___, and remains in
atrial fibrillation with rates better controlled on Metoprolol
and Amiodarone. TTE showed preserved LVEF of >55%; mild aortic
stenosis; moderate mitral regurgitation; and moderate tricuspid
regurgitation.
Of additional note, TEE showed thrombus vs. atheroma in
descending thoracic Aorta. Given patient's age and
comorbidities, decision made not to pursue definite imaging with
CTA as patient would likely be poor candidate for surgical
intervention.
# CORONARIES: Unknown
# PUMP: LVEF >55%
# RHYTHM: Atrial fibrillation
=================
ACTIVE ISSUES
=================
# Atrial Fibrillation w/RVR, ?paroxysmal vs chronic, s/p
TEE-DCCV on ___ and ___. During the patient's
inpatient stay, she was in atrial fibrillation with rates
poorly-controlled in the 130s. Two cardioversions were performed
but were unsuccessful. For rate control, the patient was
initiated on Amiodarone 400mg BID x7 days (___), then 400
daily x7 days (___), then maintenance dose of 200 mg
daily; and increased home to Metoprolol XL 150 mg daily. For
anticoagulation, increased home Apixaban to 5 mg bid. The last
24 hours prior to discharge, HR 95-120 with atrial fibrillation
on telemetry.
# Toxic Metabolic Encephalopathy: Patient had waxing and waning
mental status during admission, thought to be related to
anesthesia for cardioversions, urinary tract infection, and
hospital delirium. On ___, she had alteration in mental status
and speech with transient decreased left pupil response to light
while having AFib/RVR. NCHCT was negative for stroke. She did
not have fever, leukocytosis, or localizing signs or symptoms of
infection. CXR was negative for pneumonia. Blood cultures remain
pending without growth. Urine culture grew pan-sensitive
Klebsiella. It was unclear if the patient had symptoms, but
given her delirium she was started on IV Ceftriaxone 1g q24h
(___), and on discharge Ciprofloxacin 500 mg daily
(___) to complete a total 5-day course. During the course
of the patient's hospitalization, patient's mental status would
wax and wane with evidence of sundowning daily.
# Acute on chronic diastolic heart Failure with reduced ejection
fraction: Patient with initial evidence of pulmonary edema on
CXR and new oxygen requirement. Patient was given Lasix IV to
good effect. On day of discharge, she was saturating well on
room air. Discharge weight: 69 kg.
# Aortic thrombus: TEE showed thrombus vs. atheroma in
descending thoracic aorta. Given patient's age and
comorbidities, decision made not to pursue definite imaging with
CTA as patient would likely be poor candidate for surgical
intervention. Patient was anticoagulated with apixaban 5 mg BID
as above.
==================
CHRONIC ISSUES
==================
# Hypertension: Continued metoprolol as above.
# Hyperlipidemia: Changed simvastatin to atorvastatin 40 mg
daily
# History of Multiple Falls: Likely due to combination of poor
eyesight ___ macular degeneration, poor hearing, memory deficit
and chronic foot pain/injury secondary to DJD. Fall risk
precautions.
========================
TRANSITIONAL ISSUES
========================
- Discharge weight: 69 kg
- Discharge creatinine: 1.1 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Left open femur fracture, left elbow fracture
Major Surgical or Invasive Procedure:
___ Open reduction and internal fixation of left femur,
washout, open reduction and itnernal fixation of left elbow
History of Present Illness:
___ w h/o HepC, unrestrained driver sustained MVC on way to
visit boyfriend at jail this afternoon about 2pm. Positive head
trauma, does not recall LOC, endorses hitting chest on steering
wheel. Evaluated at OSH where found to have open femur fracture
and elbow dislocation, transferred to ___ for management. Per
ED did not receive Abx or tetanus at OSH. Received tetanus and
Vancomycin x1 in ___ ED. In LLE patient denies numbness,
tingling, weakness. LUE patient endorses ___ and ___ digit
parasthesias and hand weakness.
Head/neck/torso imaging negative per report. No pain outside of
LUE and LLE.
Past Medical History:
Hepatitis C
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Examination
General: NAD, AAOx3
Vitals: 97.4 70 121/96 15 97% RA
LUE - obvious deformity/ecchymosis/edema at elbow with hand
resting in pronation. WWP distally with 2+ radial pulse.
Tenderness to palpation at distal radius and elbow.
Sensation markedly diminished ___ and ___ digits, also
diminished dorsum of hand.
Motor limited by pain and pt compliance - pt minimally fires
EPL, wrist extension ___, wrist flexion ___, DIO ___, unable to
cross ___ digits with difficulty thumb palmar adduction,
unable to make full fist but able to squeeze two fingers with
hand. Deltoid intact. Bicep/tricep limited by elbow pain.
RUE - no ecchymosis, erythema, deformity
Non tender to palpation
WWP with 2+ radial pulse.
Sensation intact R/U/M
EPL/FDP/FDS/wrist extension/wrist flexion/biceps/triceps ___
LLE - 1x1cm lateral thigh puncture wound without bleeding,
erythema, visible bone or soft tissue or debris. Non tender
foot/ankle/leg/hip. Sensation intact throughout. ___
___ strength. WWP distally with 2+ ___.
RLE - no ecchymosis, erythema, deformity
Non tender to palpation throughout.
Sensation intact throughout. ___ ___ strength. WWP
distally with 2+ ___.
Discharge Physical Examination
General: Awake, alert, no acute distress
AFVSS
LLE: warm, well perfused, sensation intact to light touch in
S/S/SP/DP/Tib, good motor function in ___
RLE: LLE: warm, well perfused, sensation intact to light touch
in median ulnar distributions, sensation decreased in ulnar
distribution, motor function in EPL/FDS/FDP/EDC/DIO
Pertinent Results:
Imaging:
___ Plain Films Left Femur 0057: There is one shaft width
lateral and anterior displacement of the transversely oriented
midshaft left femur fracture with mild angulation. There is
19-mm overriding of the fracture fragments. Foci of
subcutaneous air are consistent with the history of open
fracture. Expected marked soft tissue swelling. The
femoracetabular joint is intact bilaterally. There is no
sacroiliac or pubic symphyseal diastasis.
___ Plain Films Left Elbow: Displaced olecranon fracture.
___ Intra-Op Films Left Femur 0928: Images from the
operating suite show placement of an intramedullary rod about a
previously described fracture of the mid shaft of the femur.
Further information can be gathered from the procedure report.
Laboratory:
___ 09:45PM BLOOD WBC-15.1* RBC-4.33* Hgb-12.8* Hct-39.2*
MCV-91 MCH-29.7 MCHC-32.8 RDW-12.5 Plt ___
___ 09:45PM BLOOD ___ PTT-32.9 ___
___ 09:45PM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-139
K-4.7 Cl-103 HCO3-26 AnGap-15
___ 09:45AM BLOOD WBC-10.2 RBC-3.57* Hgb-10.6* Hct-31.5*
MCV-88 MCH-29.8 MCHC-33.8 RDW-12.5 Plt ___
___ 09:45AM BLOOD Glucose-139* UreaN-7 Creat-0.6 Na-136
K-4.1 Cl-103 HCO3-27 AnGap-10
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 injection daily Disp #*14 Syringe
Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
When PCA off; hold if excess sedation, RR<10, O2sat<92%
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Open left midshaft femur fracture.
Closed left elbow dislocation and proximal ulnar fracture,
Monteggia variant.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with open femoral and elbow fracture, status
post reduction and splint placement. Evaluate.
COMPARISONS: None available.
TECHNIQUE: ONE VIEW PELVIS, THREE VIEWS LEFT FEMUR
FINDINGS: There is one shaft width lateral and anterior displacement of the
transversely oriented midshaft left femur fracture with mild angulation.
There is 19-mm overriding of the fracture fragments. Foci of subcutaneous air
are consistent with the history of open fracture. Expected marked soft tissue
swelling.
The femoracetabular joint is intact bilaterally. There is no sacroiliac or
pubic symphyseal diastasis.
Radiology Report
INDICATION: ___ female with open elbow fracture status post reduction
and placement of a splint for alignment. Evaluate.
COMPARISON: Left elbow radiograph from ___ performed on
the same day of this study.
EIGHT TOTAL VIEWS OF THE LEFT WRIST, ELBOW, AND FOREARM
There is a displaced fracture of the olecranon with mild angulation and a
10-mm gap. Small ossific fragments measure up to 6-mm in the antecubital
fossa and may arise from the olecranon fracture or coronoid process. Overall
alignment has improved following reduction.
Artifact from the cast limits assessment of the wrist, but the carpal rows are
aligned and no fractures are observed.
IMPRESSION: Displaced olecranon fracture. Improved overall alignment.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show placement of an intramedullary
rod about a previously described fracture of the mid shaft of the femur.
Further information can be gathered from the procedure report.
Radiology Report
INDICATION: Left elbow ORIF.
COMPARISON: ___.
Eight fluoroscopic spot images of the left elbow demonstrate placement of
cerclage wires and K-wires across the olecranon fracture in overall improved
alignment. The total fluoroscopic time is 5.3 seconds. For the further
details, please see the intraoperative note.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with FX FEMUR NOS-OPEN, MV COLLISION NOS-DRIVER
temperature: 97.4
heartrate: 70.0
resprate: 15.0
o2sat: 97.0
sbp: 121.0
dbp: 96.0
level of pain: 10
level of acuity: 2.0 | The patient was admitted to the orthopaedic surgery service on
___ with open, left, midshaft femur fracture and closed,
left olecronon fracture. Patient was taken to the operating
room and underwent washout, open reduction, internal fixation
with intramedullary nail of left femur and open reduction and
internal fixation of left elbow. Patient tolerated the
procedure without difficulty and was transferred to the PACU,
then the floor in stable condition. Please see operative report
for full details.
Musculoskeletal: prior to operation, patient was NWB LUE, LLE.
After procedure, patient's weight-bearing status was
transitioned to NWB LUE, WBAT LUE. Throughout the
hospitalization, patient worked with physical therapy and
occupational therapy. A posterior orthoplast splint was
fashioned for patient to wear while resting.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: the patient suffered an acute blood loss anemia
with HCT drop from 39.2 preoperatively to 31.2
post-operatively.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #_. the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incisions were clean, dry, and intact without
evidence of erythema or drainage; the LUE and LLE were NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of diabetes
mellitus, HTN, HLD, dementia and mental retardation s/p multiple
falls who presents after a fall at home.
History limited due to patient's cognitive deficits. As per
niece who is primary caretaker, patient was seated after eating
breakfast in the kitchen around 10am. Niece had gone to another
room when she heard patient fall. SHe states that patient most
likely tried to get up on her own, and fell in the process. She
found the patient on the floor, conscious, responsive. It
appears the patient did not lose consciousness although patient
could not verify this. Only complaint was headache at the site
of head strike. Niece denies any LOC, changes in behavior,
fevers, vomiting, chest pain, shortness of breath.
Neice reports patient has a long history of falls at home with
ROS positive for brief staring spells, brief periods of shaking
of extremities. Briefly, in ___, she had two ED visits for
possibly orthostatic syncope with negative workup, discharged
after metoprolol was dc'd. Again in ___, admitted for
syncope, attributed to othostatic hypotension (despite IVF and
compression stockings). All BP meds were held at ___ and trialed
on fludrocortisone. Workup included a TTE (only g1dd), MRI (just
showed mild mesial temporal atrophy), EEG (normal). Given
recurrent episodes, neurology trialed her on Keppra for possible
seizures. Per niece, no seizures since initiation of Keppra.
In ED, VS: 98.2 80 157/78 18 100% RA. Labs showed positive
UA (>182 WBC, mod bact, large ___, WBC 8.6, Cr 1.1, Mg 1.4. CT
spine with degenerative changes but no fracture. CT head without
contrast showed no ICH and small right frontal hematoma without
fracture. CXR without ingiltrates. UCX pending. Given Tylenol,
CTX 1gm IV, Mg SO4 2gm. Admitted to medicine for UTI
Past Medical History:
DIABETES MELLITUS
DEMENTIA/ MENTAL RETARDATION
?KIDNEY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
Social History:
___
Family History:
Mother reportedly died of a stroke.
Physical Exam:
Admission PE
Gen: Pleasant, cooperative, oriented to self only (baseline)
HEENT: Small hematoma on right frontal area
Neck: No JVD, no carotid bruits
CV: RRR, nl S1 S2, no murmurs
Lungs: CTA b/l
Abd: Soft, non tender, non distended, +BS
Extremities: No edema
Skin: fragile skin
Neuro: CN II-XII grossly normal, moving all 4 extremities
grossly
Discharge PE:
98 118/69 62 18 100 RA
Gen: Pleasant, cooperative, oriented to self only (baseline)
HEENT: Small hematoma on right frontal area
Neck: No JVD, no carotid bruits
CV: RRR, nl S1 S2, no murmurs
Lungs: CTA b/l
Abd: Soft, non tender, non distended, +BS
Extremities: No edema
Neuro: CN II-XII grossly normal, moving all 4 extremities
equally
Pertinent Results:
___ 12:40PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.4*
___ 12:40PM WBC-8.6 RBC-3.64* HGB-11.2 HCT-34.5 MCV-95
MCH-30.8 MCHC-32.5 RDW-12.7 RDWSD-44.2
___ 12:40PM NEUTS-84.5* LYMPHS-7.3* MONOS-5.8 EOS-1.5
BASOS-0.6 IM ___ AbsNeut-7.24* AbsLymp-0.63* AbsMono-0.50
AbsEos-0.13 AbsBaso-0.05
___ 02:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
CT L-Spine
1. No evidence of acute lumbar spinal fracture.
2. Grade 1 anterolisthesis of L4 on L5.
3. Severe degenerative changes of the lumbar spine, most
pronounced at L3-L4 and L4-L5. At L3-L4, there is a large
posterior disc bulge causing moderate central canal narrowing.
Chest PA/L
No acute intrathoracic process. Gaseous distention of loops of
bowel
partially imaged and not well assessed on this study
CT head
1. No acute intracranial hemorrhage.
2. Small right frontal subgaleal hematoma without underlying
fracture.
3. Small focal polypoid lesion in the right nasal cavity is
unchanged since ___
CT c-spine
1. No evidence of fracture or malalignment.
2. Severe multilevel degenerative changes with severe spinal
canal narrowing and multiple levels of severe neural foraminal
narrowing are similar in appearance since ___.
TTE (___): The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. 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) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity size with preserved regional and global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Mild pulmonary hypertension
EEG (___): Normal routine EEG in wakefulness. There were no
focal
abnormalities or epileptiform features.
___ 2:10 pm URINE
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 250 mg PO DAILY
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. LOPERamide 2 mg PO TID:PRN diarrhea
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. GlipiZIDE 10 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*10 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. GlipiZIDE XL 10 mg PO BID
5. LevETIRAcetam 250 mg PO DAILY
6. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
7. LOPERamide 2 mg PO TID:PRN diarrhea
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
UTI
Fall
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with s/p fall, unclear head strike // eval for fx,
pna, ich
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Cardiac and mediastinal silhouettes are stable. No focal consolidation is
seen. There is no pleural effusion or evidence of pneumothorax. No displaced
fracture is identified. Gaseous distention of loops of bowel is partially
imaged. Evidence of DISH is seen along the thoracic spine.
IMPRESSION:
No acute intrathoracic process. Gaseous distention of loops of bowel
partially imaged and not well assessed on this study.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, unclear head strike. 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 18.0 s, 18.3 cm; CTDIvol = 49.4 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT head of ___ and MR head of ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes. An
8 mm pineal cyst is unchanged (602b:42).
There is no evidence of acute fracture. A small subgaleal hematoma underlies
the right frontal scalp (3:44). The previously described oblong soft tissue
density in the right nasal cavity with remottling of the adjacent bone,
measuring 1.4 x 0.7 cm (601b:22), has not changed since the prior study.
There is mucosal thickening in the bilateral maxillary sinuses. The
visualized portion of the remaining paranasal sinuses and middle ear cavities
are clear. There is underpneumatization of the bilateral mastoid air cells,
as seen on the prior study. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Small right frontal subgaleal hematoma without underlying fracture.
3. Small focal polypoid lesion in the right nasal cavity is unchanged since
___.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with s/p fall, unclear head strike. Evaluate for cervical
spinal fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 22.3 cm; CTDIvol = 37.1 mGy (Body) DLP = 828.5
mGy-cm.
Total DLP (Body) = 828 mGy-cm.
COMPARISON: Cervical spine CT of ___.
FINDINGS:
Alignment is normal. No fractures are identified. There is no prevertebral
soft tissue swelling.
Severe degenerate changes of the cervical spine are most pronounced at C5
through C7, where there is complete loss of disc space. Spinal canal
narrowing is present at multiple levels, most severe at C6-C7, as described on
the prior study. There is no evidence of infection or neoplasm.
Biapical pleural parenchymal scarring with right upper lobe bronchiectasis is
unchanged since the prior study. The imaged thyroid is normal.
IMPRESSION:
1. No evidence of fracture or malalignment.
2. Severe multilevel degenerative changes with severe spinal canal narrowing
and multiple levels of severe neural foraminal narrowing are similar in
appearance since ___.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ with L1 tenderness to palpation after a fall. Evaluate
for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.8 s, 26.6 cm; CTDIvol = 32.0 mGy (Body) DLP = 850.5
mGy-cm.
Total DLP (Body) = 850 mGy-cm.
COMPARISON: Lumbar spinal radiograph of ___.
FINDINGS:
There is grade 1 anterolisthesis of L4 on L5.No acute lumbar spinal fracture
detected.Severe degenerative changes of the lumbar spine are most pronounced
at L4-L5, where there is endplate sclerosis, severe disc space narrowing, and
osteophytosis. There is a large posterior disc bulge causing moderate central
canal narrowing at L3-L4. There is no prevertebral soft tissue swelling.
Incidental note is made of a large amount of hyperdense stool in the colon.
IMPRESSION:
1. No evidence of acute lumbar spinal fracture.
2. Grade 1 anterolisthesis of L4 on L5.
3. Severe degenerative changes of the lumbar spine, most pronounced at L3-L4
and L4-L5. At L3-L4, there is a large posterior disc bulge causing moderate
central canal narrowing.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with Urinary tract infection, site not specified
temperature: 98.2
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 157.0
dbp: 78.0
level of pain: yes
level of acuity: 3.0 | A/P: ___ year old female with a history of diabetes mellitus,
HTN, HLD, mental retardation, history of multiple falls
(possibly due to seizures), who presents after a fall at home,
and found to have an UTI.
# Fall: Per her niece most likely a mechanical fall but unclear,
possibly a seizure. She is currently on Keppra 250mg daily,
which is a minimal dose, however this appears to have worked in
the recent past. Falls in elderly is multifactorial, and ddx
includes orthostasis (given known history and suspected
autonomic dysfunction), mechanical fall, etc. TTE and
EKG/telemetry findings have been normal in the past, therefore
low suspicion for cardiogenic causes. Also EEG has not shown any
abnormalities in ___. She had no further falls or concerning
events. Orthostatics were negative.
# UTI: Presents after a fall and found to have grossly positive
UA. Unclear if she is having symptoms but urine culture growing
>100,000 gram negative rods. Started on ceftriaxone. No known
history of resistant organisms.
- Discharged on 5 day course of Macrobid
- Follow up urine culture
# HTN: Normotensive currently. In the past, has been suspected
to have autonomic dysfunction associated orthostatic
hypotension.
- Continue home HCTZ, lisinopril and metoprolol XL.
# HLD
- Continue atorvastatin
# DM
- Continue home glipizide.
# FEN: Regular diet
# Access: PIV
# Code: Full (confirmed)
# PPX: SQH
# Dispo: home with services |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fevers, rigors, anorexia
Major Surgical or Invasive Procedure:
NONE during this admission
s/p ___ Cysto right stent placement. Right extracorporeal
shock wave lithotripsy (ESWL).
History of Present Illness:
___ w/ recent ESWL and R ureteral stent placement w/ worsening
fevers, rigors and anorexia who presents to ED with
leukocytosis, creatinine elevation and urinalysis concerning for
UTI and concern for pyelonephritis/urosepsis. Presently,
hemodynamically stable and without flank pain.
Past Medical History:
HTN
DM (NIDDM)
HYPERLIPIDEMIA
DEPRESSION
GERD
NEPHROLITHIASIS
ESWL w/ right ureteral stent placement on ___
History of eye surgery ___
Social History:
___
Family History:
Lung cancer in mother, history of CAD in family.
Physical Exam:
WDWN male, nad, avss
abdomen soft, nt/nd
no CVAT
extrems w/out edema, pitting, pain
Pertinent Results:
___ 06:55AM BLOOD WBC-7.3 RBC-4.39* Hgb-11.6* Hct-35.9*
MCV-82 MCH-26.4* MCHC-32.3 RDW-16.4* Plt ___
___ 06:50AM BLOOD WBC-6.0 RBC-4.16* Hgb-11.1* Hct-33.9*
MCV-82 MCH-26.8* MCHC-32.8 RDW-16.4* Plt ___
___ 07:00AM BLOOD WBC-9.5 RBC-4.40* Hgb-12.0* Hct-36.6*
MCV-83 MCH-27.3 MCHC-32.8 RDW-16.2* Plt ___
___ 02:10PM BLOOD WBC-11.8* RBC-4.84 Hgb-13.2* Hct-39.8*
MCV-82 MCH-27.2 MCHC-33.1 RDW-15.6* Plt ___
___ 06:55AM BLOOD Neuts-82.1* Lymphs-9.8* Monos-7.5 Eos-0.3
Baso-0.3
___ 02:10PM BLOOD Neuts-90.2* Lymphs-4.8* Monos-4.0 Eos-0.9
Baso-0.1
___ 06:55AM BLOOD Glucose-158* UreaN-15 Creat-1.2 Na-137
K-3.6 Cl-100 HCO3-26 AnGap-15
___ 06:50AM BLOOD Glucose-177* UreaN-17 Creat-1.3* Na-136
K-3.5 Cl-101 HCO3-24 AnGap-15
___ 07:00AM BLOOD Glucose-180* UreaN-23* Creat-1.7* Na-133
K-3.8 Cl-99 HCO3-22 AnGap-16
___ 02:10PM BLOOD Glucose-169* UreaN-21* Creat-1.6* Na-128*
K-3.8 Cl-95* HCO3-22 AnGap-15
___ 02:10PM BLOOD ALT-33 AST-27 AlkPhos-56 TotBili-0.5
___ 06:55AM BLOOD Calcium-8.1* Phos-1.7* Mg-2.1
___ 06:50AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.8
___ 2:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
THIS IS A CORRECTED REPORT (___).
Reported to and read back by ___ AT 1:58PM ON
___.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
ESCHERICHIA COLI.
10,000-100,000 ORGANISMS/ML. PRESUMPTIVE
IDENTIFICATION.
PREVIOUSLY REPORTED AS (___).
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
___ 2:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ UCx Results:
___ (MRN ___ DOB: ___
Encounter Date: ___
URINE CULTURE
Status: Final result Visible to patient: This result is not
viewable by the patient. Next appt: ___ at 11:00 AM
in Urology ___, MD) Dx: UTI (lower urinary
tract infection)
URINE CULTURE: Less Than 10,000 CFU/mL Gram Negative Rods,
Lactose Fermenters
with (A)
URINE CULTURE: Entc. faecalis
>100,000 cfu/mL (A)
Culture & Susceptibility
ENTC. FAECALIS
Antibiotic Sensitivity Unit Method
AMPICILLIN Sensitive MIC
CIPROFLOXACIN Sensitive MIC
LEVOFLOXACIN Sensitive MIC
NITROFURANTOIN Sensitive MIC
PENICILLIN Sensitive MIC
TETRACYCLINE Resistant MIC
VANCOMYCIN Sensitive MIC
Specimen Collected: ___ 1:08 ___ Last Resulted: ___
10:27 AM Order Details View Encounter Lab and Collection Details
Routing Result History
Exam Information
Exam Date
___
Result Information
Result Date and Time Status Provider ___
___ 10:27 AM Final result -- Abnormal Reviewed
Medications on Admission:
Medications - Prescription
ATORVASTATIN - atorvastatin 40 mg tablet. 1 (One) tablet(s) by
mouth at bedtime - (Prescribed by Other Provider)
FAMOTIDINE [PEPCID] - Pepcid 20 mg tablet. 1 (One) tablet(s) by
mouth as needed for heartburn - (Prescribed by Other Provider)
FLUOXETINE - fluoxetine 40 mg capsule. 1 (One) capsule(s) by
mouth in am - (Prescribed by Other Provider)
METFORMIN - metformin 500 mg tablet. 1 (One) tablet(s) by mouth
twice a day - (Prescribed by Other Provider)
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every
four (4) hours as needed for pain - (Prescribed by Other
Provider: ___
Medications - OTC
ACETAMINOPHEN - acetaminophen 325 mg tablet. 1 to 2 tablet(s) by
mouth every six (6) hours as needed for pain - (Prescribed by
Other Provider; Dose adjustment - no new Rx)
ASPIRIN - aspirin 81 mg chewable tablet. 1 (One) tablet(s) by
mouth once a day last dose ___ - (Prescribed by Other
Provider; Dose adjustment - no new Rx)
OMEGA 3-DHA-EPA-FISH OIL [FISH OIL] - Fish Oil 100 mg-160
mg-1,000 mg capsule. 1 (One) capsule(s) by mouth once a day last
dose ___ - (Prescribed by Other Provider; Dose adjustment
- no new Rx)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain/fever
2. Atorvastatin 40 mg PO DAILY
3. Famotidine 20 mg PO Q12H Heartburn
4. Fluoxetine 40 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
breakthrough pain only(score>4)
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ONE tablet(s)
by mouth Q4hrs Disp #*25 Tablet Refills:*0
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
thru ___
RX *ciprofloxacin 500 mg ONE tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 14
Days
through ___
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg ONE
capsule(s) by mouth twice a day Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis (Fevers, altered mental status, anorexia, rigors,
leukocytosis)
Acute renal injury
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: ___ with AMS // infiltrate?
COMPARISON: None
FINDINGS:
AP portable upright view of the chest. Lungs are clear without focal
consolidation, effusion or pneumothorax. Heart size appears top-normal. The
mediastinal contour is normal. Imaged osseous structures are intact.
Overlying EKG leads are present.
IMPRESSION:
No acute intrathoracic process
Radiology Report
INDICATION: History: ___ with ureter stent // position
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: None available
FINDINGS:
A double-J stent is seen running from the right renal pelvis to the bladder.
There are vague opacities overlying the right kidney as well as in the mid
portion of the left kidney, which may represent stones.
The bowel gas pattern is otherwise normal. The visualized portion of the bowel
loops are not dilated.
The bony structures are unremarkable.
IMPRESSION:
1. Right double -J ureteral stent is seen in the appropriate location. 2.
Residual kidney stones in the right and left kidney.
Radiology Report
INDICATION: ___ w/ fevers status post Cysto right stent placement. Right
extracorporeal shock wave lithotripsy (ESWL). // evaluate stone burden
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. The patient was lying in the prone position.
Non-contrast scan has several limitations in detecting vascular and
parenchymal organ abnormalities, including tumor detection.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was not administered.
DOSE: DLP: 420.30 mGy-cm (abdomen and pelvis.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
The lung bases are clear. The visualized heart and pericardium are
unremarkable.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of intrahepatic or extrahepatic biliary dilatation.
Cholelithiasis is present without signs of cholecystitis.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. A right nephroureteral
stent is in place with the upper pigtail looped in an upper pole calyx and the
lower pigtail looped in the bladder. Bilateral renal calculi are again seen.
Multiple small stacked stones are again seen in the right kidney in the
interpolar region and lower pole. The largest conglomerate of stones is in the
lower pole and overall measures 1.4 x 0.8 cm. Additionally, multiple small
stone fragments are seen along the mid aspect of the right ureter (series 7,
image 50). Both stacked areas of stones measure 1.3 cm in craniocaudal
dimension. A single stone in a left upper pole calyx measures 1.5 x 1.0 cm.
GASTROINTESTINAL: Small and large bowel loops demonstrate normal caliber.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
A Foley is present within a relatively collapsed bladder. 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.
IMPRESSION:
1. Moderate stone burden in the right kidney after lithotripsy. Right NU
stent in expected position with steinstrasse in the right mid ureter.
2. Left renal calculus also present.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, CHILLS POST OP
Diagnosed with FEVER, UNSPECIFIED
temperature: 102.8
heartrate: 86.0
resprate: 18.0
o2sat: 98.0
sbp: 127.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is admitted to urology voiding without difficulty but
with pain, fever, rigors and mild anorexia. Emergency department
work-up finds leukocytosis and acute renal injury. Urine
cultures from ___ and ED were pending at time of admission but
he was started on Ceftriaxone for urosepsis vs pyelonephritis.
His pain was less severe upon arrival to the floor and he was
flushed with intravenous fluids, flomax and intravenous pain
medications. Infectious disease consult was obtained. He had
fevers nightly so a foley was placed for full decompression of
his urinary system. With the identification and sensitivity
date of his urine cultures and resolution of his fevers, his
foley catheter was removed and he was converted to oral therapy.
He was evenutally discharged home with a two week course of dual
oral therapy. At discharge, patient's pain well controlled with
oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He was
given explicit instructions to complete his antibiotics and
follow up as directed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Pentasa / Pravastatin /
Lisinopril / Nitrofurantoin / adhesive
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with history of HTN, Crohn's,
osteoporosis who presents with fall.
Early in the morning patient walked across the room without her
cane reaching for jelly beans, fell and landed on her buttocks
and right wrist. She denies head strike or loss of
consciousness. She reports right wrist pain and right hip pain.
The right hip pain is consistent with her baseline as she fell
one year ago and underwent a THA and ORIF of the femur and has
had significant pain since that time. She reports ongoing pain
tonight but is unsure if it is increased from her baseline.
Patient denies numbness/tingling in the hand.
In the ED, initial vital signs were: 98 74 170/66 16 94%
Exam notable for head normocephalic, atraumatic, R wrist with
minimal ROM. TTP at distal radius. 2+ distal pulses.
Imaging notable for: R wrist xray with comminuted
intra-articular distal radius fracture with minimal angulation,
impacted fracture of the distal radial metaphysis with
intra-articular extension, as well as a comminuted fracture of
the ulnar styloid, Fractured inferior pubic ramus and right
parasymphyseal region. Right
sacral fracture. Possible fracture of the anterior acetabulum on
the right. Additionally CT pelvis showed wall thickening of the
neo terminal ileum.
Patient was evaluated by orthopedic surgery who reduced the
radial fracture and placed a splint with plan for short arm cast
___.
Labs were notable for WBC 10.3 with 83% polys H/H 13.7/42.2. UA
with no nitrites, no leuks, no bacteria.
Patient was given 25mg PO tramadol, 2.5mg IV morphine x3, 4mg IV
zofran, acetaminophen 650mg PO, 1L NS at 75cc/hr, 1G IV
ceftriaxoe.
Initial plan had been to admit to orthopedic surgery for further
management. However, patient was febrile to tmax 102, acutely
hypoxic to ___ (not recorded in ED dashboard) requiring
supplemental O2 via nasal cannula. Blood and urine cultures
obtained. Chest xray from earlier in the day with no evidence of
infiltrate, suggestion of vascular congestion. Patient was then
admitted to medicine for further workup of fever and for pain
management of R hip and radius, wrist fractures.
On Transfer Vitals were:
99.0 82 137/59 20 93% on 2L
On arrival to the floor:
Patient was tired and asking to sleep. Not in any acute pain, no
shortness of breath. No abdominal pain, nausea, vomiting. She
denies numbness or paresthesias in bilateral upper and lower
extremities.
REVIEW OF SYSTEMS:
(+) as above per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Fall while ambulating without cane resulting in multiple pelvic
fractures and right distal radius fracture in ___
(Fractured inferior pubic ramus and right parasymphyseal region;
right sacrum; possible fracture of the anterior acetabulum on
the right)
COPD per ___ PFTs
Lung Cancer s/p Cyberknife
Crohn's disease post ileocolonic resection with endoscopic
recurrence, was on infliximab until diagnosis of lung cancer.
Irritable bowel syndrome
HTN
Osteopenia/osteoporosis
Allergic rhinitis
Right proximal humerus fracture
Osteoporosis
Right femoral neck fracture s/p hemiarthroplasty
Hemorrhoids
Tobacco Abuse
Social History:
___
Family History:
no history of cancer, mother died of complications from DMII,
brother has h/o CAD
Physical Exam:
ADMISSION EXAM
=================
Vitals: 98.5 86 143/55 92% on 4L NC
General: older woman, tired appearing, breathing comfortably
speaking in full sentences, in NAD
HEENT: ACAT, PERRL, MMM, conjunctiva without pallor or erythema,
oropharynx without erythema or exudate
Lymph: no anterior or posterior cervical lymphadenopathy
CV: RRR, S1, S2 without m/r/g
Lungs: poor air movement, scattered wheezes throughout, no
crackles or rhonchi
Abdomen: soft, non distended, non tender to deep palpation, +
reducible inguinal hernia, +BS
GU: no CVA tenderness, foley in place with yellow urine
Ext: warm, well perfused, R upper extremity in splint with
mobility of digits, unable to test cap refill ___ nail ___,
sensation intact, RLE movement limited by pain, moving bilateral
lower extremities without deficits, no bruising, edema,
ecchymosis noted. 2+ dp and pt pulses bilaterally ; no lower
extremity edema
Neuro: axox3, CNII-XII grossly intact, no focal deficits,
sensation intact
Skin: warm, well perfused, no bruising or ecchymosis
.
DISCHARGE EXAM:
===========================
Vitals: 98.6 132/51 74 20 91% on 3L
General: awake and alert. sitting in chair, breathing
comfortably with O2 via nasal canula and speaking in full
sentences, in NAD
HEENT: NC/AT. PERRL, MMM, OP Clear. Neck supple.
CV: RRR, S1, S2 without m/r/g
Lungs: poor air movement, coarse breath sounds, no crackles or
rhonchi
Abdomen: soft, non distended, non tender to deep palpation,
+reducible inguinal hernia, +BS
GU: No foley
Ext: warm, well perfused, R upper extremity in short cast with
mobility of digits, sensation intact, about to move at the
elbows but range of motion limited by pain in the right lower
arm. Moving bilateral lower extremities without deficits or
pain, no bruising, edema, ecchymosis noted. Tender to palpation
at the right hip. 2+ dp and pt pulses bilaterally ; no lower
extremity edema
Neuro: a&ox3, CNII-XII grossly intact, no focal deficits,
sensation intact
Skin: warm, well perfused
Pertinent Results:
ADMISSION LABS:
===================
___ 08:40PM BLOOD WBC-10.3*# RBC-4.45# Hgb-13.7 Hct-42.2
MCV-95 MCH-30.8 MCHC-32.5 RDW-13.8 RDWSD-47.8* Plt ___
___ 08:40PM BLOOD ___ PTT-31.5 ___
___ 08:40PM BLOOD Glucose-141* UreaN-14 Creat-0.6 Na-136
K-3.7 Cl-97 HCO3-27 AnGap-16
___ 09:01PM BLOOD Lactate-1.1
.
___ VITAMIN D - 16
___ 07:48AM BLOOD %HbA1c-6.1* eAG-128*
CULTURES:
===================
___ Blood cultures - Negative
___ Urine culture - Negative
___ Sputum - Contaminated
___ Urine culture - Pending
___ C. Diff - Negative
___ Stool Culture
IMAGING:
===================
___
HIP UNILAT MIN 2 VIEWS IMPRESSION:
No evidence of periprosthetic lucency, or fracture.
CT PELVIS ORTHO W/O C
1. Fractured inferior pubic ramus and right parasymphyseal
region. Right
sacral fracture. Possible fracture of the anterior acetabulum on
the right.
2. Suggestion of active inflammation of the neo terminal ileum.
3. Continued followup of adnexal cyst is recommended, as per
prior ultrasound.
WRIST(3 + VIEWS) RIGHT IMPRESSION:
Impacted fracture of the distal radial metaphysis with
intra-articular
extension, as well as a comminuted fracture of the ulnar
styloid.
WRIST(3 + VIEWS) RIGHT IMPRESSION:
There has been interval placement of an overlying cast which
obscures fine
bony detail. Acute impacted distal right radial fracture is
again seen.
There is persistent mild dorsal angulation of the distal
fracture fragments.
No new displaced fracture identified.
CHEST (PA & LAT)IMPRESSION:
No acute fractures identified. Mild pulmonary vascular
congestion.
CHEST (PORTABLE AP)IMPRESSION:
Mild interstitial pulmonary edema. No acute focal consolidation.
CT C-SPINE W/O CONTRASTIMPRESSION:
1. No evidence for an acute fracture. No acute subluxation.
2. Stable 7 mm spiculated pulmonary nodule in the right upper
lobe dating back to ___. Emphysema.
CT HEAD W/O CONTRAST IMPRESSION:
No evidence for acute intracranial abnormalities.
___
CTA CHEST W&W/O C&RECON
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mild apparent interval increase in the size of the nodules
within the right upper lobe, though comparison is limited due to
non breath hold technique performed on the PET-CT.
3. Background emphysema with superimposed radiation pneumonitis
and scarring within the right lower lobe given prior CyberKnife
therapy. It is difficult to evaluate for tumor infiltration.
4. Bilateral atelectasis with superimposed left pneumonia.
Obstruction of segmental airways bilaterally, which may be
related to aspiration. Multiple predominantly peripheral tiny
peribronchovascular nodules, likely related to
infectious/inflammatory etiology.
5. Small bilateral pleural effusions, right greater than left.
___
CHEST (PORTABLE AP)
Interval development of moderate pulmonary edema. There is also
worsening left retrocardiac opacity could be
atelectasis/consolidation. New bilateral pleural effusions. No
pneumothorax. The heart is mildly enlarged.
___
CHEST (PORTABLE AP)
AS COMPARED TO THE PREVIOUS RADIOGRAPH, THE PRE-EXISTING SIGNS
OF PULMONARY EDEMA HAVE SUBSTANTIALLY DECREASED IN SEVERITY.
HOWEVER, LIKELY ATELECTATIC OPACITIES AT THE LUNG BASES PERSIST
IN ALMOST UNCHANGED MANNER. BORDERLINE SIZE OF THE CARDIAC
SILHOUETTE IS STABLE.
___
CARDIAC ECHO (TTE): pending
.
DISCHARGE LABS:
====================
___ 06:03AM BLOOD WBC-6.6 RBC-3.75* Hgb-11.4 Hct-35.2
MCV-94 MCH-30.4 MCHC-32.4 RDW-13.6 RDWSD-46.8* Plt ___
___ 06:03AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-130*
K-3.6 Cl-90* HCO3-27 AnGap-17
___ 06:03AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Verapamil SR 240 mg PO Q24H
4. lidocaine HCl-hydrocortison ac ___ % rectal DAILY:PRN
rectal pain
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath,
wheeze
6. Nicotine Patch 21 mg TD DAILY
Discharge Medications:
1. Losartan Potassium 50 mg PO DAILY
2. Nicotine Patch 21 mg TD DAILY
3. Verapamil SR 240 mg PO Q24H
4. Acetaminophen 1000 mg PO Q8H
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath/wheezing
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Calcium Carbonate 1250 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Piperacillin-Tazobactam 4.5 g IV Q8H
11. Polyethylene Glycol 17 g PO DAILY
12. Ranitidine 150 mg PO BID:PRN heart burn
13. Senna 8.6 mg PO BID
14. Tamsulosin 0.4 mg PO QHS
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*30 Tablet Refills:*0
16. Vancomycin 750 mg IV Q 12H
17. Vitamin D 1000 UNIT PO DAILY
18. lidocaine HCl-hydrocortison ac ___ % rectal DAILY:PRN
rectal pain
19. Tiotropium Bromide 1 CAP IH DAILY
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIANGNOSIS:
========================
LLL Pneumonia
Right Pelvis Fracture
Right Radial Fracture
SECONDARY DIAGNOSIS:
========================
Hyponatremia
Urinary retention
Lung nodules
Adnexal cyst
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: WRIST(3 + VIEWS) RIGHT
INDICATION: History: ___ with fall and pain // r/o fx. s/p orif r hip
r/o fx. s/p orif r hip
TECHNIQUE: Right wrist, three views
COMPARISON: None.
FINDINGS:
There is a impacted fracture of the distal radial metaphysis with
intra-articular extension, as well as a comminuted fracture of the ulnar
styloid. The carpal rows are aligned. No sclerotic lesions are identified.
IMPRESSION:
Impacted fracture of the distal radial metaphysis with intra-articular
extension, as well as a comminuted fracture of the ulnar styloid.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: History: ___ with fall and pain // r/o fx. s/p orif r hip
r/o fx. s/p orif r hip
TECHNIQUE: AP view of the pelvis with 3 additional views of the right hip
COMPARISON: Radiographs dated back to ___.
FINDINGS:
The patient is status post right hip hemi arthroplasty, with a non cemented
femoral stem in overall appropriate anatomic alignment. The femoral head
component is seated appropriately within the acetabulum. There is no evidence
of lucency, or fracture. Vascular calcifications are re- demonstrated. Mild
degenerative changes are seen in the left hip.
IMPRESSION:
No evidence of periprosthetic lucency, or fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with fall. Evaluate for hemorrhage .
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. The patient was scanned twice due to motion on the initial
acquisition. Sagittal and coronal reformatted images were obtained.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 54.2 mGy (Head) DLP =
891.9 mGy-cm.
4) Spiral Acquisition 8.7 s, 18.1 cm; CTDIvol = 81.7 mGy (Head) DLP =
1,480.5 mGy-cm.
Total DLP (Head) = 2,372 mGy-cm.
COMPARISON: CT from ___ and MRI from ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
large vascular territorial infarction. Prominence of the ventricles and sulci
due to age-related parenchymal volume loss is again seen. Mild
periventricular hypodensities, presumably sequela of small vessel ischemic
disease, are again seen.
No acute fracture is identified. There is a small mucous retention cyst in
the right maxillary sinus. Other paranasal sinuses, middle ear cavities,
mastoid air cells, and pneumatized petrous apices are well-aerated.
A large heterogeneously ossified exophytic lesion arising from the outer table
of the petrous temporal bone on the left, behind the pinna, is again seen,
compatible with an osteoma.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall. Evaluate for 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 5.2 s, 20.3 cm; CTDIvol = 36.7 mGy (Body) DLP = 745.6
mGy-cm.
Total DLP (Body) = 746 mGy-cm.
COMPARISON: CT C-spine from ___.
FINDINGS:
The bones are severely demineralized. There is no evidence of a displaced
fracture. There is no acute subluxation. Mild anterolisthesis of C3 on C4
and mild anterolisthesis of C7 on T1 are unchanged compared to ___.
Disc protrusions and disc osteophyte complexes indent the ventral thecal sac
at multiple levels with moderate spinal canal narrowing, not significantly
changed compared to the prior CT, though evaluation of the spinal canal by CTs
limited compared to MRI. Multilevel neural foraminal narrowing by
uncovertebral and facet osteophytes is also again seen.
Emphysema is noted in the visualized upper lungs. A spiculated lung nodule at
the right upper lobe measures 7 mm by 6 mm, unchanged dating back to the
earliest available chest CT from ___.
IMPRESSION:
1. No evidence for an acute fracture. No acute subluxation.
2. Stable 7 mm spiculated pulmonary nodule in the right upper lobe dating back
to ___. Emphysema.
Radiology Report
INDICATION: History: ___ with fall // eval for bleed/fx
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiographs dated back to ___
FINDINGS:
The heart size is normal. The hilar and mediastinal contours demonstrate mild
pulmonary vascular congestion, otherwise are unremarkable. There is no
pleural effusion or pneumothorax. Fiducial marker at the right lung apex is
unchanged in position. Note is made of mild bibasilar atelectasis. No acute
fractures identified.
IMPRESSION:
No acute fractures identified. Mild pulmonary vascular congestion.
Radiology Report
INDICATION: ___ s/p reduction of r wrist // post-reduction/splinting
TECHNIQUE: AP, lateral, and oblique views of the right wrist.
COMPARISON: Exam from earlier the same day at 03:45.
FINDINGS:
There has been interval placement of an overlying cast which obscures fine
bony detail. Acute impacted distal right radial fracture is again seen.
There is persistent mild dorsal angulation of the distal fracture fragments.
No new displaced fracture identified.
Radiology Report
EXAMINATION: CT PELVIS ORTHO W/O C
INDICATION: ___ year old woman with right hip pain and inability to ambulate
// eval for occult hip fracture
TECHNIQUE: MDCT images were obtained of the pelvis. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was not administered.
Total DLP (Body) = 1,428 mGy-cm.
COMPARISON: FDG PET-CT ___ and pelvis ultrasound ___
FINDINGS:
PELVIS: Wall thickening of the neo terminal ileum measures up to 7 mm with
associated engorged vasa recta. There is some fat stranding around the distal
neo terminal ileum. The visualized large bowel is otherwise normal in caliber
without wall thickening, fat stranding, or focal mass lesion.
The visualized distal abdominal aorta is normal in caliber without aneurysmal
dilatation. Significant amount of atherosclerotic calcification noted. The
iliac arteries are normal in course and caliber.
The bladder is well distended and normal. No pelvic side-wall or inguinal
lymph node enlargement by CT size criteria. No free pelvic fluid seen. There
are multiple fat containing midline umbilical hernias. Left adnexal cyst
measures 2.2 x 1.8 cm.
OSSEOUS STRUCTURES: Fractured inferior pubic ramus and right parasymphyseal
region. Nondisplaced fracture of the right anterior sacrum. There is also a
possible right anterior acetabular fracture(2:61), however this region is
obscured by artifact from the right hip arthroplasty. Bones are
demineralized. Multilevel, multifactorial degenerative changes are seen
within the visualized spine. No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Fractured inferior pubic ramus and right parasymphyseal region. Right
sacral fracture. Possible fracture of the anterior acetabulum on the right.
2. Suggestion of active inflammation of the neo terminal ileum.
3. Continued followup of adnexal cyst is recommended, as per prior ultrasound.
Radiology Report
INDICATION: ___ year old woman with R hip fracture with acute fever 102 and
new hypoxia // acute infiltrate? volume overload?
TECHNIQUE: Portable
COMPARISON: ___
FINDINGS:
Mild interstitial pulmonary edema. No acute focal consolidation. No large
pleural effusions or pneumothorax. The hila are enlarged, but unchanged when
given for differences in technique. The cardiopericardial silhouette is not
enlarged.
IMPRESSION:
Mild interstitial pulmonary edema. No acute focal consolidation.
Radiology Report
INDICATION: ___ year old woman with HTN, Chron's, COPD, RLL lung cancer s/p
cyberknife, history of falls s/p repeat fall with right radius and pelvis
fracture now hypoxic to the 70-80s. // PE?
TECHNIQUE: Standard CT images of the with pulmonary embolism protocol.
Intravenous contrast: 100 cc of Optiray injected. No oral contrast
administered.
DOSE: Total DLP (Body) = 282 mGy-cm.
COMPARISON: Comparison is made to PET-CT images from ___.
FINDINGS:
VASCULATURE
Good quality examination with the pulmonary artery measuring up to 320
___ units. There is no evidence of central or segmental pulmonary
embolism. The main pulmonary artery is within the upper limits of normal in
size measuring up to 3.1 cm which is similar to the ascending aorta appear the
left and right main pulmonary arteries are also within upper limits of normal
in size, with the left measuring up to 2.3 cm, and the right up to 2.4 cm.
Heavy aortic calcifications of the arch and branch vessels, without
significant stenosis. Triple vessel coronary artery calcifications.
AIRWAY:
There are secretions appreciated within the central tracheobronchial tree
layering dependently in the trachea and carina. There is obstruction of the
right lower lobe apical, and basal segmental bronchi. There is also
obstruction of subsegmental over left lower lobe basal lateral, posterior, and
medial bronchi.
MEDIASTINUM:
There are bilateral small pleural effusions. No pericardial effusion.
No hilar or mediastinal lymphadenopathy is noted. No axillary
lymphadenopathy.
LUNGS:
There is a 0.6 cm nodule within the right upper lobe apical segment (03:27),
which appears marginally increased in size compared to the prior PET-CT,
allowing for differences in technique. A fiducial marker is seen immediately
inferior to this. Within the right upper lobe apical posterior segment, there
is a 1.0 x 0.9 cm nodule with slightly is irregular margins (3:66), which
appears slightly increased compared to previous measurement of 0.9 x 0.7 cm.
There is infiltrative soft tissue surrounding the right lower lobe bronchus,
similar compared to previous, with areas of scarring and cicatrization.
Stable appearance of than pneumonitis seal within the right lower lobe medial
segment.
There is a background of extensive centrilobular emphysema within the lungs,
with apical predominance. Additionally, there are multiple tiny
peribronchovascular nodules along the periphery of the lungs bilaterally, with
slight apical predominance, likely infectious/inflammatory. Multifocal areas
of septal thickening within the bases bilaterally. There is dependent
subsegmental atelectasis in bilateral bases. Additionally, within the left
lower lobe, there is evidence of superimposed consolidation, which may be
secondary to aspiration pneumonia.
OSSEOUS STRUCTURES:
Multifocal areas of degenerative changes within the spine, with multiple
compression fractures of the mid thoracic vertebral bodies. There is
resultant exaggerated thoracic kyphosis.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Mild apparent interval increase in the size of the nodules within the
right upper lobe, though comparison is limited due to non breath hold
technique performed on the PET-CT.
3. Background emphysema with superimposed scarring within the right lower
lobe given prior CyberKnife therapy. It is difficult to evaluate for tumor
infiltration.
4. Bilateral atelectasis with superimposed left pneumonia. Obstruction of
segmental airways bilaterally, which may be related to aspiration. Multiple
predominantly peripheral tiny peribronchovascular nodules, likely related to
infectious/inflammatory etiology.
5. Small bilateral pleural effusions, right greater than left.
Radiology Report
INDICATION: ___ year old woman with history of COPD, lung cancer s/p
cyberknife s/p fall with hip and R arm fracture and CAP with worsening O2
requirements. // interval change
TECHNIQUE: PORTABLE
COMPARISON: ___
FINDINGS:
Interval development of moderate pulmonary edema. There is also worsening
left retrocardiac opacity could be atelectasis/consolidation. New bilateral
pleural effusions. No pneumothorax. The heart is mildly enlarged.
IMPRESSION:
Interval development of moderate pulmonary edema and small effusion.
New left retrocardiac opacity can be consolidation/atelectasis.
Radiology Report
INDICATION: ___ year old woman with chron's disease with inflammation of colon
on CT but without GI symptoms who is with PNA, fall, pelvis and r radius
fracture. // ileus? toxic megacolon?
TECHNIQUE: Supine portable abdominal radiographs were obtained.
COMPARISON: Pelvic radiographs dated ___.
FINDINGS:
There are multiple gas-filled dilated loops of small bowel, measuring up to
3.8 cm. Some gas-filled loops of large bowel are seen. There is air within
the rectum.
There is no free intraperitoneal air, although exam limited by supine
technique.
There is diffuse demineralization and degenerative changes of the lumbar
spine. The right hip prosthesis is incompletely imaged.
IMPRESSION:
Generalized gaseous distention of predominantly small bowel likely
representing adynamic ileus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lung cancer s/p cyerknife and COPD s/p
fall with pelvis and radial fracture with LLL pnemonia and pulmonary edema.
// interval change.
COMPARISON: ___
IMPRESSION:
AS COMPARED TO THE PREVIOUS RADIOGRAPH, THE PRE-EXISTING SIGNS OF PULMONARY
EDEMA HAVE SUBSTANTIALLY DECREASED IN SEVERITY. HOWEVER, LIKELY ATELECTATIC
OPACITIES AT THE LUNG BASES PERSIST IN ALMOST UNCHANGED MANNER. BORDERLINE
SIZE OF THE CARDIAC SILHOUETTE IS STABLE.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new picc, for history of pneumonia.
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest x-ray dated ___.
FINDINGS:
A left PICC line terminates in the distal left subclavian vein. There are
moderate lung volumes. There has been interval decrease in pulmonary vascular
congestion. The left heart border and left hemidiaphragm appear more
distinct. In contrast, the right hemidiaphragm and adjacent right lower lung
have more conspicuous opacities, as compared to prior.
IMPRESSION:
1. Left PICC line terminating in the distal left subclavian vein.
2. Interval decrease in pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with picc // l picc 46cm iv ping ___
Contact name: ping, ___: ___
IMPRESSION:
Interval repositioning of left PICC, now terminating in the lower superior
vena cava. Exam is otherwise similar to the recent study from approximately 2
hr earlier except for apparent slight increase in size of moderate right
pleural effusion with adjacent worsening right basilar opacification.
Diffusely distended loops of bowel in the upper abdomen are incompletely
evaluated on this chest radiograph exam and could be more fully assessed by
abdominal imaging if warranted clinically.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain, R Wrist injury, s/p Fall
Diagnosed with FRACTURE OF PUBIS-CLOSED, FX SACRUM/COCCYX-CLOSED, FX DISTAL RADIUS NEC-CL
temperature: 98.0
heartrate: 74.0
resprate: 16.0
o2sat: 94.0
sbp: 170.0
dbp: 66.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is an ___ woman with history of HTN, COPD,
Crohn's, osteoporosis, and lung cancer s/p radiation who
presented with a fall and was found to have right pelvic
fractures and distal right radius fracture.
# Community acquired pneumonia. Patient was febrile to 102 in
the ED and hypoxic to 70-80s on room air. CT chest on ___
showed left lower lobe consolidation, small b/l pleural
effusions, and obstruction of right lower lobe bronchi likely
due to muscous plug. Blood cultures from ___ negative. Was
given levofloxacin between ___ and ___ without signifcant
improvement. Vanc/zosyn started on ___, plan for 7 day course to
be completed on ___. Required ___ of oxygen via NC during the
hospitalization, not on O2 at home.
- check Vancomycin level AM of ___
- last day of antibiotics on ___
- continue to wean oxygen
- d/c PICC after antibiotic course
# Fall resulting in right pelvis fracture and right distal
radius fracture. Mechanical fall with patient tripping on her
carpet early morning without assistive device with pneumonia as
a contributing factor. R radius fracture reduced in ED on ___
and short cast placed on ___. Right pelvis fractures
non-surgical. Lovenox was started for DVT prophylaxis. Minimal
of 2 weeks, with orthopedics to decide final course at follow up
(per ortho likely ___ weeks). Per ortho weight bearing as
tolerated for pelvic fracture and right upper extremity is
non-weight bearing. Pain control with Tramadol.
- continue to adjust pain management as needed
- help patient follow up with orthopedics on ___ in the ___
clinic
- final course of Levenox to be determined by orthopedics
# Hyponatremia: Na 130 on discharge. Likely mild SIADH due to
pneumonia and pain. Patient's Na rage 130-135 this admission.
- Continue to trend. If decreasing further further workup and
fluid restriction
# Urinary retention. Multiple episodes of PVR > 500. Foley
catheter placed and Tamsulosin started. Likely due to
combination of pain medications and pelvic pain and holding her
urine.
- Please reasess urine retention and attempt to remove foley
# Inflammation of the terminal ileum. CT pelvis with incidental
finding of terminal ileum inflammation. The patient does not
have any abominal pain and diarrhea. Stool cultures send.
- Assist patient in follow up with GI
- f/u stool cultures pending on discharge
# Vitamin D deficiency. Started on Vitamin D and Calcium
CHRONIC MEDICAL ISSUES:
# COPD. Not on home O2. Continues to smoke about a pack a day.
No evidence of acute exacerbation. Held tiotropium when using
ipratropium this admission. Continue Ipratropium Q6H and
Albuterol nebs Q4H.
- restart Tiotropium at discharge.
# Hypertension: Continue home losartan, verapamil
# TRANSITIONAL ISSUES:
- Follow up with ortho on ___
- Ortho to determine final course of Lovenox, likely ___ weeks.
- Please remove foley as urinary retention improves
- Trend hyponatremia
- Check Vancomycin level on AM of ___
- Wean oxygen with ogal O2 Sat of 88-92%
- 7 day antibiotics course to finish on ___
- f/u final read of ECHO
- CT abdomen with active inflammation of the neo terminal ileum
though no GI symptoms. Continue to monitor for GI symptoms, and
consider further treatment for Chron's
- possible small interval increase of the previously seen
nodules in PET CT.
- adenexal cyst previously seen on transvaginal US seen again on
pelvis CT. Radiology recommend ___ year follow up with US in
___
# Code: DNR/DNI confirmed with patient and daughter, HCP
# Emergency Contact: ___: Daughter
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck pain s/p fall
Major Surgical or Invasive Procedure:
___ C5/C6 ___ (___)
History of Present Illness:
___ male who sustained fall onto back of head with CT showing
widening of the anterior disc space at C5/C6 without fracture.
C/f ligamentous instablity/injury. Neuro exam intact.
Past Medical History:
PMH/PSH:
Very hard of hearing
BPH, HTN, GERD
Social History:
SH: denies tobacco, alcohol, illicit drug use. lives alone
Physical Exam:
PHYSICAL EXAMINATION:
Vitals:
98.5
92
200/98
16
99% RA
General: Well-appearing male in no acute distress.
Spine exam:
nontender to palpation over C-spine
reports pain with attempted gentle active neck flexion. no pain
with extension or neck rotation
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Hoffmans: neg
Babinski: downgoing
Clonus: none
Perianal sensation: deferred
Rectal tone: deferred
Pertinent Results:
___ 05:45PM BLOOD WBC-10.9* RBC-4.21* Hgb-13.4* Hct-39.1*
MCV-93 MCH-31.8 MCHC-34.3 RDW-13.4 RDWSD-46.2 Plt ___
___ 06:00AM BLOOD WBC-9.9 RBC-3.71* Hgb-12.0* Hct-34.4*
MCV-93 MCH-32.3* MCHC-34.9 RDW-13.4 RDWSD-45.1 Plt ___
___ 04:47AM BLOOD Neuts-70.9 ___ Monos-5.7 Eos-0.8*
Baso-0.4 Im ___ AbsNeut-8.00* AbsLymp-2.42 AbsMono-0.64
AbsEos-0.09 AbsBaso-0.04
___ 05:45PM BLOOD Plt ___
___ 06:00AM BLOOD Plt ___
___ 04:47AM BLOOD ___ PTT-30.9 ___
___ 05:45PM BLOOD Glucose-137* UreaN-19 Creat-0.9 Na-132*
K-3.5 Cl-92* HCO3-28 AnGap-16
___ 06:00AM BLOOD Glucose-86 UreaN-22* Creat-1.0 Na-134
K-3.4 Cl-95* HCO3-28 AnGap-14
___ 04:47AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-132*
K-3.8 Cl-91* HCO3-29 AnGap-16
___ 05:45PM BLOOD Calcium-9.5 Phos-4.1 Mg-1.9
___ 09:36AM BLOOD WBC-7.6 RBC-4.09* Hgb-13.0* Hct-37.9*
MCV-93 MCH-31.8 MCHC-34.3 RDW-13.0 RDWSD-44.3 Plt ___
___ 10:37AM BLOOD Neuts-71.0 Lymphs-18.7* Monos-8.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-7.47* AbsLymp-1.97
AbsMono-0.87* AbsEos-0.09 AbsBaso-0.03
___ 09:36AM BLOOD Plt ___
___ 01:19PM BLOOD Plt ___
___ 09:33PM BLOOD Glucose-123* UreaN-13 Creat-0.6 Na-137
K-3.8 Cl-100 HCO3-23 AnGap-18
___ 09:36AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-139
K-3.2* Cl-98 HCO3-26 AnGap-18
___ 01:19PM BLOOD Glucose-113* UreaN-12 Creat-0.6 Na-137
K-2.6* Cl-99 HCO3-26 AnGap-15
___ 09:36AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7
___ 01:19PM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
CXR ___:
FINDINGS:
Moderate cardiomegaly is unchanged. Mild pulmonary vascular
congestion is
seen without pulmonary edema. The patient is low lung volumes
however no
focal consolidations are seen. Previously seen crescent shaped
lucency is not clearly seen on current study.
IMPRESSION:
Previously seen crescent shaped lucency is not seen on current
study and is better evaluated on plain film abdominal radiograph
of ___.
CXR ___:
FINDINGS:
Moderate cardiomegaly is unchanged. Low lung volumes with
vascular crowding are seen. Previously seen question of
pneumoperitoneum is minimal if any. If definitive answer is
needed, recommend follow-up CT abdomen or CT torso for further
evaluation. Small right pleural effusion is unchanged.
IMPRESSION:
1. Questionable pneumoperitoneum is minimal if any.
2. Stable right pleural effusion.
KUB ___:
FINDINGS:
There is free air seen under the right hemidiaphragm on lateral
decubitus
films. There are air-filled dilated loops of small and large
bowel. Air is seen to the level of the sigmoid colon. There are
skin staples noted
projecting over the left iliac bone. Osseous structures are
notable for
degenerative changes of the spine.
IMPRESSION:
Pneumoperitoneum, likely postoperative. Comparison of serial
chest x-rays
from today reveal that pneumoperitoneum appears to be
decreasing. Bowel-gas pattern suggestive of postoperative ileus
versus obstruction. Recommend a repeat evaluation with upright
chest x-ray to ensure continued resolution of pneumoperitoneum.
KUB ___:
Medications on Admission:
pecoset, finasteride, tamsulosin, ambien, alprazolam,
omeprazole, lisinopril, triamterene-HCTZ
Discharge Medications:
1. ALPRAZolam 1 mg PO QHS:PRN insomnia
2. Bisacodyl 10 mg PO/PR DAILY
3. Cetirizine 10 mg PO DAILY:PRN allergies
4. Ciprofloxacin HCl 500 mg PO Q12H UTI
___
5. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medication
6. GuaiFENesin ER 600 mg PO Q12H:PRN for cough
7. Heparin 5000 UNIT SC BID
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*45 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY constipation
10. Pregabalin 75 mg PO Q12H
11. Finasteride 5 mg PO DAILY
12. Lisinopril 20 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: C5-6 FUSION
TECHNIQUE: C-Spine 3 views.
COMPARISON: MR cervical spine from ___
FINDINGS:
Fluoroscopic assistance provided to the surgeon in the OR without the
radiologist present. 3 spot views obtained. Fluoro time was not recorded.
Multiple steps throughout an anterior C5-6 fusion with disc prosthesis are
noted. Please see operative report for further detail.
IMPRESSION:
3 spot views obtained intraoperatively throughout an anterior C5-6 fusion with
disc prosthesis. Please see operative for further detail.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man s/p C5-C6 ACDF // postop XR; upright, ___.
postop XR; upright, ___.
IMPRESSION:
Postoperative images show anterior fusion with interbody spacer at C5-C6.
Substantial soft tissue prominence is related to the recent surgery. Further
information can be gathered from the operative report.
Significant narrowing with spurring is seen at C4-C5 and also at C3-C4.
Radiology Report
INDICATION: ___ year old man s/p ACDF with coughing // rule out pna
COMPARISON: Radiographs from ___.
IMPRESSION:
There is hardware within the lower cervical spine, new since prior study.
Heart size is upper limits of normal but stable. There is no focal
consolidation. There are low lung volumes and subsegmental atelectasis at the
right lung base. There are no pneumothoraces.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man s/p C5-6 ACDF on ___ with difficulty swallowing
// AP/Lateral re eval
TECHNIQUE: AP and lateral views of the cervical spine.
COMPARISON: Cervical spine radiographs ___.
FINDINGS:
C1-C6 visualized on the lateral projection. Compared to the prior study this
surgical drain the mean removed. The anterior cervical disc fusion hardware
at C5-6 is unchanged in appearance. Moderately severe disc space narrowing at
C4-5 and moderate narrowing at C3-4, also unchanged. The degree of
prevertebral soft tissue swelling has decreased slightly, particularly at the
C3-4 level.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p C5-6 ACDF on ___ with difficulty
swallowing, coughing // comparison CXR comparison CXR
IMPRESSION:
Compared to chest radiographs ___ and ___.
Previous pulmonary vascular congestion and edema have resolved. Mild
cardiomegaly persists. There may be new pneumo peritoneum. There is no
pneumothorax. Pleural effusions small if any. Moderate cardiomegaly
persists.
RECOMMENDATION(S): Clinical evaluation for possible pneumoperitoneum,
followed by Upright PA and lateral chest and KUB.
NOTIFICATION: The findings were discussed with ORTHO SPINE
___ ___ , M.D. by ___, M.D. on the telephone on
___ at 12:07 ___, 2 minutes after discovery of the findings.
Radiology Report
EXAMINATION: Chest x-ray PA and lateral
INDICATION: ___ year old man s/p ACDF having difficulty swallowing and
constipation now with recent cxr concerning for pneumoperitoneum // upright
PA/Lat imaging based on radiologist rec to eval for free air based on recent
imaging concerning for pneumoperitoneum
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made to chest x-rays dating from ___
through ___.
FINDINGS:
Moderate cardiomegaly is unchanged. Low lung volumes with vascular crowding
are seen. Previously seen question of pneumoperitoneum is minimal if any. If
definitive answer is needed, recommend follow-up CT abdomen or CT torso for
further evaluation. Small right pleural effusion is unchanged.
IMPRESSION:
1. Questionable pneumoperitoneum is minimal if any.
2. Stable right pleural effusion.
RECOMMENDATION(S): Recommend follow-up CT abdomen or CT torso for further
evaluation if definitive answer is needed, .
Radiology Report
INDICATION: ___ year old man s/p ACDF having difficulty swallowing and
constipation now with recent cxr concerning for pneumoperitoneum // eval for
free air given recent XR concerning for pneumoperitoneum
TECHNIQUE: Supine and lateral decubitus abdominal radiographs were obtained.
COMPARISON: Chest x-ray ___
FINDINGS:
There is free air seen under the right hemidiaphragm on lateral decubitus
films. There are air-filled dilated loops of small and large bowel. Air is
seen to the level of the sigmoid colon. There are skin staples noted
projecting over the left iliac bone. Osseous structures are notable for
degenerative changes of the spine.
IMPRESSION:
Pneumoperitoneum, likely postoperative. Comparison of serial chest x-rays
from today reveal that pneumoperitoneum appears to be decreasing. Bowel-gas
pattern suggestive of postoperative ileus versus obstruction. Recommend a
repeat evaluation with upright chest x-ray to ensure continued resolution of
pneumoperitoneum.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:04 ___, 3 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest x-ray PA and lateral
INDICATION: ___ year old man with free air on XR. // ? free air, serial exam.
TECHNIQUE: Chest AP and lateral
COMPARISON: Comparison is made to chest x-rays dating from ___
through ___.
FINDINGS:
Moderate cardiomegaly is unchanged. Mild pulmonary vascular congestion is
seen without pulmonary edema. The patient is low lung volumes however no
focal consolidations are seen. Right subdiaphragmatic lucency has been more
fully evaluated on recent abdominal radiographs, which reported free
intraperitoneal air.
IMPRESSION:
Subdiaphragmatic lucency has been more fully evaluated on recent abdominal
radiographs, reporting free intraperitoneal air.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old man s/p ACDF C5/C6 ___ (___) with imaging
concerning for pneumoperitoneam and recent cxr without further lucency
previously seen on imaging from ___ // would like to better evaluate for
pneumoperitoneum with KUB per radiology recommendationupright
TECHNIQUE: Abdomen two views
COMPARISON: ___
FINDINGS:
Previously seen pneumoperitoneum is not definitely seen today. Mildly
improved bowel distention. Degenerative changes spine.
IMPRESSION:
Pneumoperitoneum is not definitely seen today. Improved bowel distention.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Oth injuries of unspecified part of neck, init encntr, Fall on same level, unspecified, initial encounter
temperature: 98.5
heartrate: 92.0
resprate: 16.0
o2sat: 99.0
sbp: 200.0
dbp: 98.0
level of pain: 5
level of acuity: 3.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as tolerated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / Tigan / Bactrim / Percocet / sumatriptan
Attending: ___.
Chief Complaint:
recurrent falls/concern for home safety
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presenting on advice from her primary care physician because
she has had continued falls at home, with a fall yesterday
during which she suffered a left facial hematoma. She has a long
history of migraines, with a reportedly persistent migraine
since ___, accompanied by episodes of seizure-like activity
with blackouts and falls, as well as RLE weakness without other
neurological symptoms, for which she has been significantly
evaluated at this hospital, and discharge with no apparent cause
for her symptoms. Of note, she also has a significant psych
history, currently stable, however, her migraines/"seizures"
appear to be provoked by stress - her husband is currently in
the process of pursuing a separation, which she is resisting,
and according to PCP notes there is some concern that her
neurological symptoms may represent somatization vs malingering
for secondary gain.
She denies any new symptoms. She denies any headache which is
different than her baseline, she did fall and hit her head
receiving bruises yesterday, which is what brought her to her
primary care physician, and led to the ER visit subsequently.
she states that she does not recall what happened during the
'seizure' yesterday.
She denies any drugs of breath, chest ___. She denies any
vision changes. Denies any fevers, sweats, chills. She denies
any focal weakness or numbness. Reports that she has been making
progress with home ___, and that her RLE weakness has been
improving.
Initial VS in the ED were 98.4 78 125/80 19 99% Exam was notable
for right facial hematoma, labs were notable for h/h 11.9/35.3.
She reproted having had a perssitent migraine since ___ and
was admitted recently and advised to go to rehab but elected to
go home with walker and ___. Ct head showed no acute intracranial
pathology. Patient was given 2x fioricet. ED spoke with PCP who
stated that primary reason for admission is for ___
management evaluation and placement in rehab. Neuro was
curbsided and stated that given extensive outpatient workup that
has already been completed, no indication for furtehr inpatient
workup at present. VS prior to transfer were 97.5 57 125/86 16
100% RA.
On the floor, she reports persistent migrain, now ___,
secodnary to bright light exposure in the ED. Also reports ___
at right face hematoma site. No otehr complaints.
Past Medical History:
-Intractable migraines with complex features since age ___
treated by the ___ and s/p nerve blocks and
trigger point injections last ___ with previosu episodes of
complex symptoms including right hand tingling and right sided
weakness and numbness with normal imaging
-h/x previous syncopal episodes in setting of her migraines
-Non-epileptic seizures
-Chronic back ___ with right sciatica treated with gabapentin
and s/p a series of injections in the past including epidural
steroid injections, as well as targeted joint injections without
relief
-Depression
-Asthma (well controlled; on no medications)
- s/p repair right hip labrum ___
- s/p sinus surgery ___
- s/p right breast lumpectomy - benign
- s/p tonsilectomy age ___
Social History:
___
Family History:
Mother - age ___ stroke age ___ in basal ganglia with dementia and
otherwise with migraines
Maternal grandfather with a stroke at age ___.
Father - died age ___ colon ca
Sibs - 1 brother alcoholic; ___hildren - 1 daughter well; 1 son with migraines since age ___
and processing problems
There is no history of seizures, developmental disability,
neuromuscular disorders or movement disorders.
Physical Exam:
ADMISSION:
Vitals: 99.6, 114/99, 54, 16, 100% RA:
General: Alert, oriented, ___ headache.
HEENT: left sided facial hematoma across cheek. Otherwise EOMI,
PERRLA, MMM.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact. Power ___ RLE, ___. normal
tone, reflexes, coordination, sensation bilaterally. Gait
deferred.
DISCHARGE:
99.6 114/99 54 16 200%RA
General: Alert, oriented
HEENT: left sided facial bruising involving the L cheek and
orbit. EOMI, PERRLA, MMM.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact. Power ___ RUE & RLE, ___ LLE.
normal tone, reflexes, coordination, sensation bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 05:58PM BLOOD WBC-5.3 RBC-3.80* Hgb-11.9* Hct-35.3*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.1 Plt ___
___ 05:58PM BLOOD Neuts-57.0 ___ Monos-7.6 Eos-3.3
Baso-0.7
___ 05:58PM BLOOD Glucose-104* UreaN-22* Creat-0.7 Na-142
K-3.8 Cl-111* HCO3-22 AnGap-13
DISCHARGE LABS:
___ 08:05AM BLOOD ___-5.7 RBC-4.09* Hgb-12.6 Hct-38.9
MCV-95 MCH-30.7 MCHC-32.3 RDW-12.8 Plt ___
___ 08:05AM BLOOD Glucose-102* UreaN-16 Creat-0.6 Na-141
K-4.1 Cl-110* HCO3-22 AnGap-13
IMAGING:
Head CT ___:
IMPRESSION:
1. No acute intracranial process.
2. No facial bone or skull fracture identified in the imaged
portion of the head.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN migraine
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Fluoxetine 20 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Nadolol 40 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Topiramate (Topamax) 100 mg PO BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Lithium Carbonate 300 mg PO QHS
10. ZOLMitriptan *NF* 5 mg Oral QD PRN migraine
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN migraine
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Fluoxetine 20 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Gabapentin 600 mg PO TID
6. Lithium Carbonate 300 mg PO QHS
7. Nadolol 40 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Topiramate (Topamax) 100 mg PO BID
10. ZOLMitriptan *NF* 5 mg Oral QD PRN migraine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall, gait instability
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with fall yesterday.
COMPARISON: MRI of the head from ___.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head without contrast. Coronal and sagittal reformats provided and reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,
mass effect, or vascular territorial infarction. The ventricles and sulci are
normal in size and configuration. There is no fracture. The visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear. There
are no facial fractures identified.
IMPRESSION:
1. No acute intracranial process.
2. No facial bone or skull fracture identified in the imaged portion of the
head.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: FACIAL TRAUMA AFTER SZ
Diagnosed with OTHER CONVULSIONS, CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), UNSPECIFIED FALL
temperature: 98.4
heartrate: 78.0
resprate: 19.0
o2sat: 99.0
sbp: 125.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | ___ year old woman with history of depression, migraines,
recently accompanied by seizure-like episodes and right leg
weakness thought to be due to conversion disorder who presented
after a fall. She was evaluated by Psychiatry and Physical
Therapy who agreed that the patient would benefit from a stay at
a rehabilitation facility.
# Non-epileptic seizures vs Pseudoseizures: At admission the
patient reported having a fall during which she injured her face
and sustained left cheek bruising. She had a head CT in the ED
which was negative for any acute process. She was questioned
about abuse and self-harm, both of which she denied. The fall
occurred during an episode where she believes she had a
seizure-like event. Of note, in discussions with her PCP,
outpatient psychiatrist and neurologist, it appears that the
patient has a history of pseudoseizures related to conversion
disorder that are brought on by emotional stress. The patient
has a history of recurrent episodes of shaking, which resemble
seizures -- however previous EEGs have not demonstrated any
activity suggestive of true seizures. She has been evaluated by
Neurology extensively on prior admissions, and they considered
these non-epileptic seizures, due many stressors at home,
especially given her prior history of somatization and negative
Neurology work up. However, given recurrent seizures, falls and
injuries during these episodes, her PCP is concerned about the
patient's safety and requested rehab evaluation. During this
admission she was evaluated by Physical Therapy who believes
that her falls and gait instability that may improve with more
rehabilitation services. She had one witnessed episode of
pseudo-seizure activity on ___. During this episode her
vitals were stable. The patient was witnessed shaking and was
not responsive to voice for approximately 4 minutes. The patient
does not require any medication during or after these
seizure-like episodes as they are not true seizures.
# Right sided weakness/difficulty ambulating: Patient reports a
history of right sided weakness. Her PCP noted that this
weakness has improved significantly with home ___ since her last
hospitalization. Serial neuro exams during this admission showed
variable ___ weakness of right upper and lower extremities.
These exam findings appeared inconsistent when the patient was
distracted. No other neurological deficits were noted. It is
unclear if this weakness is related to conversion disorder or
associated with her migraines. Prior to discharge the patient
and her PCP agreed that the patient may benefit from more
physical rehab services.
# Depression: The patient notes that she had has many stressors
recently: daughter going to college, divorcing her husband,
selling house, and her mother is terminally ill. Psychiatry
evaluated her and believe that she does not need to go to an
inpatient psychiatric facility at this time and believe that she
is better served with follow up with her outpatient
psychiatrist. She was continued on home doses of fluoxetine and
bupropion.
# Migraines: The patient has a long history of migraines since
age ___. During this admission she had no focal neurological
deficits and negative CT head. In the past she had received
nerve blocks and trigger point injections without variable
improvement. During this hospitalization she was continued on
her home regimen of nadolol, topiramate, gabapentin, and
fioricet for her migraine ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE Pain
Major Surgical or Invasive Procedure:
Placement of Stomal Catheter (___)
Placement of Bilateral Percutaneous Nephrostomy Tubes (___)
History of Present Illness:
Ms. ___ is a ___ woman with HCV cirrhosis (s/p
Harvoni ___ w/ SVR, not active on Txpt list due to low MELD;
c/b
varices, thrombocytopenia, portal htn s/p TIPS), transitional
cell carcinoma (s/p neo-adjuvant cisplatin/gemcitabine, radical
cystectomy, urethrectomy, TAH/BSO, and ileal conduit diversion
in
___ who presented to the ED with severe RLE pain and is
admitted to the liver service for evidence of decompensated
cirrhosis.
The patient was in her usual state of health until 1 month prior
to admission when she developed sudden-onset RLE hip and
anterior
leg pain. The pain progressed from a ___ at onset to a ___
in severity and she presented to her PCP at ___
where she underwent MRI, which per the patient showed "something
the her leg compressing a nerve." She also reportedly underwent
___ which was reportedly negative for thrombus (records not
available to review). She was given percocet for pain relief
which slightly helped but mostly just sedated her. There was no
preceding trauma or activity changes. She denies associated
fevers, chills, leg swelling, erythema, or skin changes. Due to
her ongoing pain she presented to the ED.
In the ED, she was afebrile, BPs 130s/70s, and breathing 95% on
RA. She was noted to be AOx3, normal pulmonary exam, with a soft
non-distended and non-tender abdomen. Her labs were notable for
a
leukocytosis to 13.9, Hgb 15 (baseline 10), platelets 90
(baseline ___, INR of 1.8 (up from 1.4 on ___,
creatinine 4.6 (from 0.7 baseline), BUN 98 (baseline ___,
sodium 131, K 5.3, bicarb 17 w/ AnGap 21, phos 5.8, albumin 3.0
(b/s ___, lactate 2.7. Her LFTs were notable for normal
ALT/AST, alk phos 125 (down from 168), and Tbili 3.0 (up from
1.6
in ___. For her RLE pain, she had a hip Xray that showed NO
acute fracture or dislocation. There was mild degenerative
changes bilaterally w/ multiple embolization coils over the R
iliac bone. The patient was noted to be slightly confused so a
CXR was performed to r/o PNA and was unremarkable. A RUQUS was
also performed iso worsening cirrhosis labs that showed a patent
TIPS, minimal ascites, and mild splenomegaly. Of note, there was
moderate hydronephrosis involving the R collecting system.
Hepatology was consulted and recommended infectious workup,
paracenetesis (not preformed d/t no ascites), albumin for volume
resuscitation, and to hold home diuretics.
Patient received: Lidocaine patch and tramadol for pain, home
cipro SBP ppx, home rifaximin, and albumin 12.5 gm.
On arrival to the floor, the patient is in distress from pain
and
is unable to give a cohesive history due to the pain severity.
She corroborates the above story regarding her hip pain as best
as she can. She is not sure what the circumstances were around
the pain starting but denies any trauma. She endorses some mild
lower abdominal pain that is crampy in nature and relieved with
bowel movements. She denies melena or BRBPR but does endorse
intermittent diarrhea. She does not know when it started but
states it has been ongoing for at least a week. She denies any
abdominal distension, recent confusion, ___ swelling. She
denies any recent nausea or vomiting. No changes to the color or
odor of her ostomy output.
Of note, she was recently hospitalized at ___ for periostomal
variceal bleeding. She underwent successful TIPS there on
___.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Bladder cancer s/p cystectomy with ileal loop urostomy at ___
about ___ years ago
- Hepatitic C Cirrhosis
- Hypertension
- Type II Diabetes
- GERD
Social History:
___
Family History:
She has a father and mother with cirrhosis thought to be due to
alcohol. Her mother had breast cancer and her sister has lung
cancer that is metastatic to the liver and spleen.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 2211 Temp: 97.9 PO BP: 145/79 R Lying HR: 81 RR: 18
O2 sat: 92% O2 delivery: Ra
GENERAL: In acute distress from pain
HEENT: AT/NC, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, diffusely tender to palpation,
no
rebound/guarding, unable to palpate spleen d/t discomfort
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, NO asterixis, unable to participate in serial 7s or
days of week backwards due to distress from pain
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Final Physical Exam:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Pertinent Results:
ADMISSION LABS:
___ 05:41PM BLOOD WBC-13.9* RBC-4.91 Hgb-15.0 Hct-43.0
MCV-88 MCH-30.5 MCHC-34.9 RDW-20.2* RDWSD-63.1* Plt Ct-90*
___ 05:41PM BLOOD Neuts-83.3* Lymphs-6.7* Monos-8.6
Eos-0.6* Baso-0.2 Im ___ AbsNeut-11.59* AbsLymp-0.93*
AbsMono-1.20* AbsEos-0.08 AbsBaso-0.03
___ 06:02PM BLOOD ___ PTT-31.2 ___
___ 06:02PM BLOOD D-Dimer-7055*
___ 05:41PM BLOOD Glucose-100 UreaN-98* Creat-4.6*# Na-131*
K-5.3 Cl-93* HCO3-17* AnGap-21*
___ 05:41PM BLOOD ALT-12 AST-33 CK(CPK)-31 AlkPhos-125*
TotBili-3.0*
___ 05:41PM BLOOD Lipase-53
___ 08:50AM BLOOD CK-MB-4 cTropnT-0.03*
___ 03:45PM BLOOD CK-MB-4 cTropnT-0.03*
___ 05:41PM BLOOD Albumin-3.0* Calcium-9.2 Phos-5.8* Mg-2.0
___ 05:19AM BLOOD TSH-5.0*
___ 03:45PM BLOOD T4-5.0
___ 10:15AM BLOOD ASA-NEG Acetmnp-6* Tricycl-NEG
___ 10:30AM BLOOD ___ pO2-159* pCO2-28* pH-7.40
calTCO2-18* Base XS--5 Comment-GREEN TOP
___ 06:20PM BLOOD Lactate-2.7*
MICROBIOLOGY:
=================
___ 11:43 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC OF 2 MCG/ML test result performed by
Etest.
MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 32 R
VANCOMYCIN------------ =>32 R
All other blood cultures were negative
___ 12:51 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
All other urine cultures were negative
___ 11:47 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___: NEGATIVE.
IMAGING:
==============
___ (UNILAT 2 VIEW) W/P
No acute fracture or dislocation.
___ (SINGLE VIEW)
No acute cardiopulmonary process.
___ OR GALLBLADDER US
1. Moderate hydronephrosis involving the right collecting
system, new compared
to prior study. Consider CT urogram to evaluate for an
obstructing lesion in
the ureter.
2. Patent TIPS extending from the left portal vein to the left
hepatic vein,
with similar velocities and direction of flow.
3. Cholelithiasis without evidence for cholecystitis.
4. Cirrhotic liver with sequela of portal hypertension,
including minimal
perihepatic ascites fluid and mild splenomegaly measuring up to
13.5 cm.
RECOMMENDATION(S): Consider CT urogram to evaluate for an
obstructing lesion
in the ureter.
___ SCAN
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
Patchy
perfusion images with more heterogeneity on the ventilation
images and no
mismatched defects is a pattern often seen with airways disease.
___ LOW EXT W/O C RIGHT
1. Within limitations of this noncontrast CT, no suspicious
mass or evidence
of nerve compression is identified. However this is better
evaluated on MRI.
2. No acute fracture, dislocation or significant degenerative
changes.
3. Please refer to the separate report from the concurrently
performed CT
abdomen and pelvis for assessment of the intraabdominal and
pelvic structures.
___ ABD & PELVIS W/O CON
1. Dilated ileal conduit, moderate right and mild left
hydroureter, and severe
right and moderate left hydronephrosis is new from prior CT.
Findings are
concerning for ileal conduit stricture and outflow obstruction.
2. Splenic and hepatic flexure bowel wall thickening and
pericolonic
stranding, which is concerning for colitis.
3. Cirrhotic liver with TIPS in place.
4. Cholelithiasis without evidence of cholecystitis.
___ LOWER EXT VEINS
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Echo Report
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function. The
visually estimated left ventricular ejection fraction is >=60%.
There is no resting left ventricular outflow tract gradient.
Dilated right ventricular cavity with depressed free wall
motion. There is abnormal interventricular septal motion c/w
right ventricular pressure overload. The aortic sinus diameter
is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is mild to moderate [___]
tricuspid regurgitation. There is SEVERE pulmonary artery
systolic hypertension. There is no pericardial effusion.
___ PLMT NEPHROSTOMY CATHETER
Successful placement of 8 ___ nephrostomy tube on both sides.
Bilateral distal ureter narrowing.
___ CT ABD & PELVIS W/O CON
1. Mild decrease in moderate bilateral hydronephrosisstatus post
placement of bilateral percutaneous nephrostomies. Minimal
interval decrease in dilation of ileal conduit just distal to
ureteral anastomosis with collapsed segment of ileum at the
stoma site and retraction of drainage tube, which remains in
place though terminates just beyond the peritoneum. Findings
remain concerning for ileal conduit stricture and outflow
obstruction.
2. Cirrhotic liver with TIPS in place.
___ PORTABLE ABDOMEN
Gas distention of the stomach with nonspecific paucity of small
and large bowel gas which may be secondary to fluid-filled loops
of bowel, as on prior.
___ U.S.
1. Unchanged severe right and moderate left hydronephrosis.
Assessment for subtle changes in hydronephrosis may be difficult
given severity of hydronephrosis. Correlation with PCN output
is recommended.
2. Small volume ascites.
___ NEPHROSTO
Technically successful upsizing to 10 ___ bilateral
nephrostomy tubes
___ L SPINE W/O CONTRAST
1. Mild canal narrowing at the T10-T11 level from partially
calcified disc protrusion.
2. Mild bilateral neural foraminal narrowing at the L4-5 level.
3. Large right-sided facet osteophyte causing mild neural
foraminal narrowing at L5-S1 level.
4. Right total cyst at S2 level.
___ ABDOMEN
Gaseous distension of the stomach. No abnormally dilated loops
of small or large bowel.
___ ABDOMEN
Normal gaseous distension of the stomach, decreased from
radiograph dated ___.
___ ABDOMEN
Persistent gaseous distention of the stomach. There are no
abnormally dilated
loops of large or small bowel. Osseous structures are
unremarkable. The Dobhoff tube courses past the left
hemidiaphragm and terminates in the gastric body. Bilateral
nephrostomy tubes, right lower quadrant embolization coils, and
bilateral pelvic surgical
clips are unchanged in position.
___ ABD & PELVIS W/O CON
1. No new acute abdominopelvic findings.
2. Interval resolution of bilateral hydronephrosis and ileal
conduit dilation. Percutaneous nephrostomy tubes appear
appropriately placed.
3. Interval placement of a ___ feeding tube terminating in
the first part of the duodenum.
4. Cirrhotic liver with TIPS in place. Moderate ascites
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Furosemide 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. biotin 5 mg oral DAILY
9. Senna 17.2 mg PO QHS
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Lactulose 15 mL PO TID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Discharge Condition:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with R hip pain, unable to ambulate// ?fracture
TECHNIQUE: AP view of the pelvis, two views of the right hip
COMPARISON: CT abdomen pelvis ___
FINDINGS:
No acute fracture or dislocation. No diastases of the pubic symphysis or
sacroiliac joints. Mild degenerative changes of both hips with mild joint
space narrowing and lateral acetabular spurring. Clips are seen overlying the
pelvic sidewalls bilaterally and multiple embolization coils project over the
right iliac bone. Moderate atherosclerotic calcifications are seen. No focal
lytic or sclerotic osseous abnormality.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
INDICATION: History: ___ with confusion PNA?// confusion, PNA?
TECHNIQUE: Supine AP view of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are
unremarkable. Pulmonary vasculature is normal. Lungs are clear. No focal
consolidation, pleural effusion, or pneumothorax. Embolization coils project
over the distal mediastinum. No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with HCV cirrhosis, here with jaundice and
confusion. Evaluation for liver pathology.
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Comparison to ultrasound from ___.
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is minimal
perihepatic ascites. There is stable splenomegaly, with the spleen measuring
13.5 cm. There is no intrahepatic biliary dilation. The CHD measures 5 mm.
Several gallstones are again noted within the gallbladder which is mildly
distended, without evidence gallbladder wall thickening.
The main portal vein is patent with hepatopetal flow.
The TIPS extends from the left portal vein into the left hepatic vein.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 43 cm/sec, previously 51 cm/sec
Proximal TIPS: 62 cm/sec, previously 69cm/sec
Mid TIPS: 118 cm/sec, previously 152 cm/sec
Distal TIPS: 120 cm/sec, previously 125 cm/sec
Flow within the anterior and posterior right portal veins is towards the TIPS
shunt. Appropriate flow is seen in the hepatic veins and IVC.
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.
KIDNEYS: Limited views of the kidneys demonstrate moderate hydronephrosis
involving the right kidney, new compared to prior study. The right kidney
measures 14.4 cm. The left kidney measures 13.1 cm.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Moderate hydronephrosis involving the right collecting system, new compared
to prior study. Consider CT urogram to evaluate for an obstructing lesion in
the ureter.
2. Patent TIPS extending from the left portal vein to the left hepatic vein,
with similar velocities and direction of flow.
3. Cholelithiasis without evidence for cholecystitis.
4. Cirrhotic liver with sequela of portal hypertension, including minimal
perihepatic ascites fluid and mild splenomegaly measuring up to 13.5 cm.
RECOMMENDATION(S): Consider CT urogram to evaluate for an obstructing lesion
in the ureter.
Radiology Report
EXAMINATION: CT RIGHT LOWER EXTREMITY WITHOUT CONTRAST
INDICATION: ___ year old woman with cirrhosis, p/w severe ___ pain in RLE,
had previous MRI and was told there was a mass in her thigh compressing her
nerves// Source of RLE pain, ? mass
TECHNIQUE: MDCT images were acquired through the right lower extremity from
the right hip through the mid tibia and fibula without the administration of
IV contrast. Coronal and sagittal reformats were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 77.2 cm; CTDIvol = 13.6 mGy (Body) DLP =
1,049.3 mGy-cm.
Total DLP (Body) = 1,049 mGy-cm.
COMPARISON: Radiographs of the pelvis and right hip ___. CT
abdomen and pelvis ___.
FINDINGS:
No evidence of osseous malignancy, infection, fracture or dislocation. No
significant right knee joint effusion. Vascular calcifications are moderate.
Right inguinal lymph nodes are prominent but within normal limits, measuring
up to 12 mm (series 301, image 41).
For assessment of the intraabdominal and pelvic structures, please see the
separate report from the concurrently performed CT abdomen and pelvis.
IMPRESSION:
1. Within limitations of this noncontrast CT, no suspicious mass or evidence
of nerve compression is identified. However this is better evaluated on MRI.
2. No acute fracture, dislocation or significant degenerative changes.
3. Please refer to the separate report from the concurrently performed CT
abdomen and pelvis for assessment of the intraabdominal and pelvic structures.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old woman with HCV cirrhosis s/p TIPS and transitional
cell carcinoma s/p urostomy here with severe ___, RLE pain, and persistent
nausea and vomiting// Evaluate L spine for RLE pain, for SBO/LBO for
persistent nausea/vomiting, and hydronephrosis/urostomy for ___.
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 3.8 s, 50.7 cm; CTDIvol = 21.8 mGy (Body) DLP =
1,101.6 mGy-cm.
Total DLP (Body) = 1,102 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Mild atelectasis at the lung bases, bilaterally.
ABDOMEN:
HEPATOBILIARY: Cirrhotic liver morphology. Left hepatic vein to left portal
vein TIPS shunt is noted, but incompletely evaluated without intravenous
contrast. Cholelithiasis without evidence of cholecystitis. No suspicious
hepatic lesions on limited assessment.
PANCREAS: No suspicious pancreatic lesions or pancreatic ductal dilatation on
limited assessment.
SPLEEN: The spleen measures at the upper limits of normal (13.1 cm).
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Moderate left and severe right hydronephrosis, new from ___.
2.9 cm cystic structure at the posterior aspect of the right kidney, is
compatible with a cyst. Punctate nonobstructing stones in the left kidney are
noted.
GASTROINTESTINAL: Small hiatal hernia. Small bowel loops demonstrate normal
caliber and wall thickness throughout. There is moderate splenic flexure
colonic wall thickening and adjacent fat stranding (series 2, image 34).
Similarly there is focal fat stranding adjacent to the hepatic flexure (series
2, image 36). The interposed transverse colon appears grossly unremarkable.
A small bowel containing umbilical hernia is noted without evidence of
obstruction. There is colonic diverticulosis without evidence of
diverticulitis. The appendix is normal.
PELVIS: The patient is status post cystectomy. A right lower quadrant ileal
conduit is moderately distended up to 5.7 x 4.6 x 6.6 cm (series 2, image 62).
There is tube within the conduit as it passes through the patient's stoma.
Metallic coils in the region the stoma likely represent previously embolized
parastomal varices.
REPRODUCTIVE ORGANS: The patient is status post hysterectomy and per report
salpingoophorectomy
LYMPH NODES: Additional prominent gastrohepatic, omental, retroperitoneal
lymph nodes are not enlarged by CT size criteria. Findings may be reactive to
the patient's underlying cirrhosis. Right inguinal lymph nodes measure at the
upper limits of normal.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
IMPRESSION:
1. Dilated ileal conduit, moderate right and mild left hydroureter, and severe
right and moderate left hydronephrosis is new from prior CT. Findings are
concerning for ileal conduit stricture and outflow obstruction.
2. Splenic and hepatic flexure bowel wall thickening and pericolonic
stranding, which is concerning for colitis.
3. Cirrhotic liver with TIPS in place.
4. Cholelithiasis without evidence of cholecystitis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with history of bladder cancer, now with R hip
pain and RLE pain. STE changes on ECG concerning for PE, w/u ongoing.
Evaluation for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. Of note, there is an
enlarged right inguinal lymph node measuring 1.4 x 1.4 x 2.3 cm, better
assessed on CT abdomen/pelvis performed earlier the same day.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
INDICATION: ___ year old woman with hydronephrosis and history of bladder
resection and ileal conduit formation.
COMPARISON: ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___
Interventional ___ and Dr. ___, Interventional Radiology
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: General sedation was provided by anesthesia.
MEDICATIONS: Please see anesthesia note for medication details.
CONTRAST: 25 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 9.6 minutes, 113 mGy
PROCEDURE: 1. Bilateral ultrasound guided renal collecting system access.
2. Bilateral nephrostogram.
3. Bilateral 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 and left flank was prepped and draped in the usual sterile
fashion.
The right renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. 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 in the collecting system. Contrast injection confirmed
appropriate positioning. The catheter was then flushed, 0 silk stay sutures
applied and the catheter was secured with a Stayfix device and sterile
dressings. The catheter was attached to a bag.
The left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. 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 in the collecting system. Contrast injection confirmed
appropriate positioning. The catheter was then flushed, 0 silk stay sutures
applied and the catheter was secured with a Stayfix device and sterile
dressings. The catheter was attached to a bag.
FINDINGS:
Contrast injected into both kidneys demonstrated severe bilateral
hydronephrosis. Contrast was seen passing through the distal ureter and into
the ileal conduit on both sides; however, there was significant stenosis in
both distal ureters.
IMPRESSION:
Successful placement of 8 ___ nephrostomy tube on both sides.
Bilateral distal ureter narrowing.
RECOMMENDATION(S): Keep both PCNs to external drainage.
Plan is to convert to internal stents in the near future.
Radiology Report
INDICATION: ___ year old woman with dobhoff placement// dobhoff placement
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
The Dobhoff tube projects below the left hemidiaphragm and projects over the
stomach. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen
Radiology Report
EXAMINATION: Fluoroscopic guided nasogastric tube advancement
INDICATION: ___ year old woman with dobhoff// please advance post-pyloric
DOSE: Acc air kerma: 111 mGy; Accum DAP: 2432.8 uGym2; Fluoro time: 6 minutes
and 44 seconds
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, attempted to advance the existing Dobhoff feeding tube
was post-pylorically using a guidewire; however, were unsuccessful. Attempts
were stopped due to patient's reported intolerable pain and excess fluoro
time.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Unsuccessful post-pyloric advancement of a Dobhoff feeding tube. The Dobhoff
tips remains in her stomach. The patient will be called back the subsequent
day for an additional attempt.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: ___ year old woman with HCV cirrhosis// Question about fluid
accumulation, infection s/p bilateral nephrostomy drains and if kidneys
decompressed
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: Total DLP (Body) = 1,126 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There is a new small left pleural effusion and bibasilar
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates a cirrhotic morphology with 2 left
portal vein TIPS re-demonstrated, as on prior. There is no evidence of focal
lesions within the limitations of an unenhanced scan. There is no evidence of
intrahepatic or extrahepatic biliary dilation. The gallbladder contains
gallstones without wall thickening or evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is enlarged measuring up to 14 cm though demonstrates
normal 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 placement of bilateral percutaneous
nephrostomy with bilateral moderate hydronephrosis, with mild interval
decrease in hydronephrosis in comparison to the prior examination of ___. The percutaneous nephrostomy catheters are appropriately positioned
with pigtail in the renal pelves. A 2.8 cm right renal cyst is
re-demonstrated. No nephrolithiasis. Minimal perinephric inflammatory
stranding.
The patient is status post cystectomy with ileal conduit and a right lower
quadrant stoma. A catheter enters the stoma though terminates at the level of
the peritoneum with the portion of ileum collapsed adjacent to the stoma site
with a re-demonstrated dilated segment of ileum just distal to ureteral
anastomosis which now measures 4.7 x 3.6 cm previously measuring 5.7 x 4.6 cm.
Embolization coils at the level of the stoma are re-demonstrated and likely
represent previously embolized parastomal varices.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Colonic diverticulosis is
noted, without evidence of wall thickening and fat stranding. The appendix is
normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral ovaries are surgically absent.
LYMPH NODES: Multiple prominent gastrohepatic, omental, and retroperitoneal
lymph nodes are demonstrated but not enlarged by CT size criteria, likely
reactive. 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: A nonobstructed small bowel containing umbilical hernia is
re-demonstrated and unchanged.
IMPRESSION:
1. Mild decrease in moderate bilateral hydronephrosisstatus post placement of
bilateral percutaneous nephrostomies. Minimal interval decrease in dilation of
ileal conduit just distal to ureteral anastomosis with collapsed segment of
ileum at the stoma site and retraction of drainage tube, which remains in
place though terminates just beyond the peritoneum. Findings remain
concerning for ileal conduit stricture and outflow obstruction.
2. Cirrhotic liver with TIPS in place.
Radiology Report
INDICATION: ___ year old woman with HCV cirrhosis with poor PO intake//
advance to post-pyloric
DOSE: Acc air kerma: 102 mGy; Accum DAP: 2296.2 uGym2; Fluoro time: 8 minutes
and 46 seconds.
COMPARISON: CT abdomen pelvis dated ___ confirmed placement
prior to advancement.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was advanced
post-pylorically using a guidewire.
25 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the first
portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use.
Radiology Report
INDICATION: ___ year old woman with HCV cirrhosis on tube feeds s/p N/V x2.//
evaluate for obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: NG tube repositioning from ___ and CT abdomen
pelvis from ___
FINDINGS:
There is gaseous distention of the stomach with an overall paucity of small
and large bowel gas which is nonspecific and may be secondary to fluid-filled
loops as demonstrated on prior CT abdomen pelvis.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
A Dobhoff tube is re-demonstrated and terminates in the proximal duodenum as
on recent fluoroscopy study. Bilateral percutaneous nephrostomy tubes are
re-demonstrated. Surgical clips are visualized in the bilateral pelvis.
Peristomal embolization coils are demonstrated in the right lower quadrant. A
rectal tube is partially visualized
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Gas distention of the stomach with nonspecific paucity of small and large
bowel gas which may be secondary to fluid-filled loops of bowel, as on prior.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman w/ HCV cirrhosis, transitional cell carcinoma
s/p ileal conduit, has had bad RLE pain.// h/o lumbar disc disease, evaluate
w/ MRI h/o lumbar disc disease, evaluate w/ MRI
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal T1 images.
Patient developed acute hallucinations and was deemed inappropriate for
follow-up contrast study.
COMPARISON: No prior dedicated lumbar imaging
CT abdomen pelvis dated ___
FINDINGS:
Alignment is normal. Focal fatty deposit appreciated in the L3 vertebral
body. The spinal cord appears normal in caliber and configuration.
T10-T11:
The partially calcified disc protrusion encroaches on the left anterolateral
aspect of the spinal cord.
L3-L4, L4-L5:
Minimal bulging from the intervertebral disc with facet osteophytes
bilaterally. This has led to mild bilateral neural foraminal narrowing at the
L4-L5 level.
L5-S1:
Large right-sided facet osteophyte causing mild neural foraminal narrowing.
Incidental finding of a right Tarlov cyst at the S2 level, please correlate
clinically.
Additionally, there is interval increase in free pelvic fluid in comparison.
IMPRESSION:
1. Mild canal narrowing at the T10-T11 level from partially calcified disc
protrusion.
2. Mild bilateral neural foraminal narrowing at the L4-5 level.
3. Large right-sided facet osteophyte causing mild neural foraminal narrowing
at L5-S1 level.
4. Right total cyst at S2 level.
NOTIFICATION: Regarding the increased in free pelvic fluid, discussed with
Dr. ___ ___, who will communicate with the primary team. Also discussed
with Dr. ___ abdominal imaging, who suggests a repeat CT abdomen pelvis at
there is a clinical concern.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with cirrhosis and ileal conduit after
cystectomy for transitional cell carcinoma s/p b/l PCNU for obstructive
nephropathy who now has worsening UOP and creatinine// evaluate for worsening
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Prior examinations, most recent CT from ___ most
recent ultrasound from ___
FINDINGS:
Again seen is severe hydronephrosis on the right and moderate hydronephrosis
on the left, unchanged compared to CT from ___ and ultrasound
from ___. Bilateral percutaneous nephrostomy tubes are not well
visualized on this ultrasound. No stones or masses are identified
bilaterally. There is cortical thinning of both renal cortices.
Right kidney: 12.9 cm
Left kidney: 12.8 cm
The bladder is only minimally distended, with catheter in place. As such, the
bladder can not be fully assessed on the current study.
Incidentally noted small volume ascites.
IMPRESSION:
1. Unchanged severe right and moderate left hydronephrosis. Assessment for
subtle changes in hydronephrosis may be difficult given severity of
hydronephrosis. Correlation with PCN output is recommended.
2. Small volume ascites.
Radiology Report
INDICATION: ___ year old woman with HCV cirrhosis and ileal conduit s/p
cystectomy for transitional cell carcinoma p/w acute renal failure s/p b/l
PCNUs, now with poor drainage, leakage, and rising creatinine.// Please upsize
PCNUs.
COMPARISON: Renal ultrasound from the same day and previous placement
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
2mcg of fentanyl and 200 mg of midazolam throughout the total intra-service
time of 20 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: None
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE:
PROCEDURE:
1. Bilateral diagnostic antegrade nephrostogram.
2. Bilateral 8 ___ nephrostomy to 10 ___ nephrostomy upsizing.
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 in
the decubitus position on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right and left flank were prepped and
draped in the usual sterile fashion.
Diluted contrast was injected into the left nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered with
instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The
catheter was cut. A ___ wire was advanced into the left nephrostomy tube
and advanced into the distal ureter. The stay sutures were cut and the
catheter was removed over the wire. A new 10 ___ nephrostomy catheter was
flushed and advanced with its plastic stiffener over the wire into appropriate
position. The wire and stiffener were removed and the pigtail was formed.
Contrast injection confirmed appropriate positioning. The final image was
saved. The catheter was then flushed, stay sutures applied and the catheter
was secured with a Stat Lock device and sterile dressings. The catheter was
attached to a bag for drainage.
Diluted contrast was injected into the right nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered
with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection.
The catheter was cut. A ___ wire was advanced into the right nephrostomy
tube and advanced into the distal ureter. The stay sutures were cut and the
catheter was removed over the wire. A new 10 ___ nephrostomy catheter was
flushed and advanced with its plastic stiffener over the wire into appropriate
position. The wire and stiffener were removed and the pigtail was formed.
Contrast injection confirmed appropriate positioning. The final image was
saved. The catheter was then flushed, stay sutures applied and the catheter
was secured with a Stat Lock device and sterile dressings. The catheter was
attached to a bag for drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Appropriate final position of ___ F bilateral nephrostomy tube.
Hydronephrosis remains. Frank pus drained from the collecting systems
IMPRESSION:
Technically successful upsizing to 10 ___ bilateral nephrostomy tubes
Radiology Report
INDICATION: ___ year old woman with ongoing nausea// eval for obstruction
TECHNIQUE: Portable supine abdominal radiograph
COMPARISON: Prior abdominal radiograph dated ___.
FINDINGS:
Unchanged gaseous distention of the stomach. No abnormally dilated loops of
small or large bowel. No large volume free air.
Osseous structures are unremarkable. Dobhoff seen terminating in the gastric
body. Bilateral nephrostomy tubes, bilateral pelvic surgical clips, and right
lower quadrant embolization coils are unchanged in position.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Gaseous distension of the stomach. No abnormally dilated loops of small or
large bowel.
Radiology Report
INDICATION: ___ year old woman with abdominal distention and large amount of
stomach air// interval changes
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Multiple prior abdominal radiographs, most recent dated ___.
FINDINGS:
Normal gaseous distension of the stomach, decreased from radiograph dated ___. No abnormally dilated loops of large or small bowel.
Osseous structures are unremarkable. Dobhoff seen coursing past the left
hemidiaphragm and terminating in the pylorus or the first part of the
duodenum. Bilateral nephrostomy tubes, bilateral pelvic surgical clips, and
right lower quadrant embolization coils are unchanged in position.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Normal gaseous distension of the stomach, decreased from radiograph dated ___..
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxemia// evaluate for edema/effusion
evaluate for edema/effusion
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS ___ AND ___.
Feeding tube passes into stomach substantially distended with air and fluid.
Lungs fully expanded and clear. Cardiomediastinal and hilar silhouettes and
pleural surfaces are normal.
Radiology Report
INDICATION: ___ year old woman with HCV cirrhosis now w/ dobhoff placement//
dobhoff placement
COMPARISON: Radiographs from ___
IMPRESSION:
Serial images demonstrate placement of a Dobhoff tube with the distal tip
projecting over the distal stomach. Pigtail catheters project over the right
and left upper abdomen. Lungs are grossly clear.Heart size is within normal
limits.
Radiology Report
INDICATION: ___ year old woman with HCV cirrhosis w/ dobhoff// please advance
post-pyloric. Do not cut bridle (has been tied from previous dobhoff and is
not attached to current one).
DOSE: Acc air kerma: 49 mGy; Accum DAP: 1328.9 uGym2; Fluoro time: 5 minutes
and 43 seconds
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, attempted to advance the existing Dobhoff feeding tube
post-pylorically using a guidewire.
40 cc of Optiray contrast were used to confirm placement. Final fluoroscopic
spot images demonstrated the tip of the feeding tube in the stomach.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Unsuccessful post-pyloric advancement of a Dobhoff feeding tube. The tube
terminates in the stomach. Excess slack was left in the stomach. Recommend
repeat KUB in evening to re-evaluate tube placement, as it may advance
spontaneously.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:22 am, 45 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with HCV cirrhosis// S/p dobhoff placement
Contact name: ___: ___
IMPRESSION:
In comparison with the study of ___, both images show the opaque
portion of the Dobhoff tube in the subcarinal part of the esophagus.
Otherwise, the examination is within normal limits.
NOTIFICATION: Dr. ___
Radiology Report
INDICATION: ___ year old woman with dobhoff// dobhoff
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The Dobhoff tube projects below the left hemidiaphragm and over the stomach.
Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen
Radiology Report
EXAMINATION: Feeding tube advancement
INDICATION: ___ year old woman with dobhoff placed needs to be advanced post
pyloric unable to tolerate tube feeds currently, attempted ___ unsuccessul//
advance dobhoff post pyloric, please do NOT cut bridle, not currently around
dobhoff
TECHNIQUE: See below
DOSE: Acc air kerma: 19 mGy; Accum DAP: 498.1 uGym2; Fluoro time: 02:44
COMPARISON: None.
FINDINGS:
The right nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was advanced using a
guidewire. The weighted tip of the Dobhoff tube reached the pyloric orifice
but was unable to be advanced further due to distension of the stomach.
10 cc of Optiray contrast were used to confirm position. Final fluoroscopic
spot images demonstrated the tip of the feeding tube in the gastroduodenal
junction.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Advancement of a Dobhoff feeding tube to the pyloric orifice with failure to
advance further due to an overly distended stomach. Repeat imaging in ___
hours is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:30 pm, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with cirrhosis// Attempted to advance dobhoff
post-pyloric but left in stomach. Has dobhoff advanced post-pyloric?
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Same day fluoroscopic images.
FINDINGS:
Persistent gaseous distention of the stomach. There are no abnormally dilated
loops of large or small bowel.
Osseous structures are unremarkable. The Dobhoff tube courses past the left
hemidiaphragm and terminates in the gastric body. Bilateral nephrostomy
tubes, right lower quadrant embolization coils, and bilateral pelvic surgical
clips are unchanged in position.
IMPRESSION:
Dobhoff tube courses past the left hemidiaphragm and terminates in the gastric
body.
Radiology Report
INDICATION: Ms. ___ is a ___ woman with HCV cirrhosis (s/p
Harvoni ___ w/ SVR, not active on Txpt list due to low MELD; c/b varices,
thrombocytopenia, portal htn s/p TIPS), transitional cell carcinoma (s/p
neo-adjuvant cisplatin/gemcitabine, radical cystectomy, urethrectomy, TAH/BSO,
and ileal conduit diversion in ___ who presented to the ED with severe RLE
pain and is admitted to the liver service for evidence of decompensated
cirrhosis, ___, RLE pain with ongoing abdominal pain and intolerance of tube
feed with previous narrowing of ileal conduit seen on ___ CT AP
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 4.2 s, 55.2 cm; CTDIvol = 23.0 mGy (Body) DLP =
1,266.0 mGy-cm.
Total DLP (Body) = 1,266 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Stable appearance of bibasilar atelectasis and left-sided small
pleural effusion..
ABDOMEN:
HEPATOBILIARY: The liver demonstrates cirrhotic morphology with small amount
of ascites. Re-demonstrated are two left portal vein TIPS, unchanged compared
to prior. There is no evidence of focal lesions within the limits of this
unenhanced scan.. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder contains gallstones without wall
thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions 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. Again seen are
bilateral percutaneous nephrostomy tubes in appropriate positions with
interval resolution of bilateral hydronephrosis. A 2.8 cm right renal cyst
again seen, unchanged compared to the prior exam. There is no
nephrolithiasis. There is no perinephric abnormality.
The patient is status post cystectomy with ileal conduit in the right lower
quadrant stoma. embolization coils are again seen at the level of the stoma,
likely secondary to previous embolization. Stoma and anastomosis appear
stable when compared to prior exam. Previously identified dilated ileal loop
is not visualized on the present study.
GASTROINTESTINAL: The stomach is distended with air. An Dobhoff tube is seen
coursing along the greater curvature of the stomach terminating in the first
part of the duodenum. Small bowel loops demonstrate normal caliber and wall
thickness throughout. Colonic diverticulosis without wall thickening or fat
stranding. The appendix is not visualized, however no secondary signs of
appendicitis are noted..
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral ovaries are surgically absent.
LYMPH NODES: Multiple gastrohepatic, omental, retroperitoneal lymph nodes are
again noted but are not enlarged by CT size criteria. 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: A nonobstructive small bowel containing umbilical hernia is
noted, unchanged from prior exam.
IMPRESSION:
1. No new acute abdominopelvic findings.
2. Interval resolution of bilateral hydronephrosis and ileal conduit dilation.
Percutaneous nephrostomy tubes appear appropriately placed.
3. Interval placement of a Dobhoff feeding tube terminating in the first part
of the duodenum.
4. Cirrhotic liver with TIPS in place. Moderate ascites
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg pain
Diagnosed with Pain in right lower leg, Acute kidney failure, unspecified, Acute viral hepatitis, unspecified
temperature: 98.9
heartrate: 85.0
resprate: 20.0
o2sat: 93.0
sbp: 144.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ was a ___ year old woman with a history notable for
HCV c/b cirrhosis (s/p Harvoni, TIPS), transitional cell
carcinoma (s/p gem-cis chemotherapy, cystectomy w/ileal loop
urostomy), HTN and T2DM who presented to ___ with RLE pain and
was found to have severe hydronephrosis and associated acute
obstructive renal failure, bacteremia, decompensated cirrhosis,
and severe pulmonary hypertension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Patient is a ___ yo male with HTN, BPH, aflutter on coumadin who
presents following a syncopal episode today. He states that this
morning, he got up from bed and was ok initally. He wanted to go
to the bathroom; however his wife was using it so he went to the
kitchen, turned on the water to make coffee, and remembers
starting to feel lightheaded after turning on the faucet. He
then remembers being on all fours and then losing consciousness.
He denies any tunneled vision, tonic clonic movements, chest
pain, palpitations, SOB. He denies pain in his legs. When he
started feeling lightheaded, he state that he felt his pulse and
it seemed like he was skipping heartbeats.
His wife discovered him on the floor. Per patient he voided on
himself after this episode but had no tongue biting. He denies
any confusion upon gaining consciousness. He states that
yesterday he had one episode of large volume watery diarrhea but
to compensate he drank a lot of water.
On arrival to the ED, initial vitals were:98.1 74 127/80 16 97%
He got a CXR that was clear and a head CT that showed no
intracranial bleeding. Toponins were negative, an INR was 1.7,
and a glucose was 135. An EKG showed RBBB but no ischemia. His
BUN/Cr was 33/1.3, with baseline per Atrius records being
Cr1.12-1.18. While in the ED, he had another episode of a large
volume watery stool.
On the floor, he was orthostatic with BP 130/77 HR 75 standing,
BP 122/85 HR 68 sitting, BP 97/54 HR 80 standing.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-atrial flutter on coumadin: Per Atrius records he has had a
couple episodes during which he felt lightheaded and felt an
irregular pulse. In ___, was found in OSH ED to be in
aflutter with variable block and slow rate, but later converted
to sinus rhythm spontaneously. Was on metoprolol until
___, but d/c'ed due to hypotension.
-BPH: s/p prostatectomy ___
-HTN
-anxiety
-depression
-MVP
-MR
Social History:
___
Family History:
FX: Father died of MI. Mother died of ___.
Physical Exam:
ADMISSION EXAM
==============
VS - Temp 97.5 F, 130/78BP , 65 HR , 19 R , 99O2-sat % RA
General: NAD
HEENT: no scleral icterus, OP clear.
Neck: supple, no cervical ___.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP No pedal edema.
Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory
function grossly intact. Refelxes +2 and symmetrical. Some mild
intention tremor on f-n-f. No pronator drift.
Skin: no rashes.
DISCHARGE EXAM
==============
VS - Temp 98.3 F, 120/66BP (120-170/60-80), 70 HR (60-80), 18 R
, 96 RA
Tele: HR in ___. In NSR.
General: NAD
HEENT: no scleral icterus, OP clear.
Neck: supple, no cervical ___.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP No pedal edema.
Neuro: A+O, attentive.
Skin: no rashes.
Pertinent Results:
EKG
====
___ Cardiovascular ECG
NSR. 1st degree AV block. RBBB. Unchanged from previous on
___.
IMAGING STUDIES
===============
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
No acute cardiopulmonary process.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
ADMISSION LABS
==============
___ 07:02AM BLOOD WBC-6.3 RBC-4.76 Hgb-14.8 Hct-42.5 MCV-89
MCH-31.0 MCHC-34.7 RDW-14.4 Plt ___
___ 07:02AM BLOOD Neuts-71.4* ___ Monos-7.9 Eos-1.2
Baso-0.6
___ 07:25AM BLOOD ___ PTT-32.0 ___
___ 07:02AM BLOOD Plt ___
___ 07:02AM BLOOD Glucose-135* UreaN-33* Creat-1.3* Na-138
K-4.0 Cl-107 HCO3-19* AnGap-16
___ 07:02AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.1
DISCHARGE LABS
==============
___ 08:10AM BLOOD WBC-6.1 RBC-4.58* Hgb-13.9* Hct-41.1
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.7 Plt ___
___ 08:10AM BLOOD ___ PTT-37.9* ___
___ 08:10AM BLOOD Glucose-105* UreaN-21* Creat-1.1 Na-139
K-3.9 Cl-107 HCO3-23 AnGap-13
___ 08:10AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terazosin 5 mg PO HS
2. Finasteride 5 mg PO DAILY
3. Warfarin 7.5 mg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. BuPROPion (Sustained Release) 150 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Finasteride 5 mg PO DAILY
3. Mirtazapine 30 mg PO HS
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Warfarin 7.5 mg PO DAILY
7. Terazosin 5 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Cardiac syncope
- Orthostatic hypotension
SECONDARY DIAGNOSES:
- Atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Pt on Coumadin, status post syncope and fall.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were acquired.
CTDIvol: 891.93
DLP: 54.53
COMPARISON: None.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or acute
major infarction. The ventricles and sulci are otherwise normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation. Incidental ___ cisterna magna versus
cerebellar atrophy is noted.
No fracture is identified. A mucous retention cyst is seen within the right
maxillary sinus. The remainder of the visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: Chest pain, syncope.
COMPARISON: None available.
TECHNIQUE: Portable frontal chest radiographs.
FINDINGS:
The heart is top normal in size. The mediastinal and hilar contours are within
normal limits. No focal consolidation, pleural effusion or pneumothorax is
identified.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with SYNCOPE AND COLLAPSE
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | IMPRESSION: ___ with PMH significant for hyperlipidemia,
hypertension, BPH (with reported history of urinary
incontinence), atrial flutter (on anticoagulation) presenting
with a syncopal episode.
# SYNCOPE - Symptomatic arrthymic event vs. sinus pause vs.
orthostatic hypotension with resulting syncope most likely
etiology given clinical history. Has history of atrial flutter
with slow ventricular response. Despite urinary incontinence,
seizure seemed unlikely as no tongue biting or tonic clonic
movement. No infectious concerns. EKG and cardiac biomarkers not
consistent with ACS/MI. Posterior circulation 'drop attack' less
likely. Had remained sinus on telemetry. U/A neg for infection
but trace protein. At___ cardiology was involved given the
concern for atrial flutter with some bradycardia and symptomatic
pauses and recommended a home cardiac event monitor which will
be mailed to his home in ___ days and he will follow-up for
consideration of nodal ablation with PPM in the future. He is
not to drive until this is further evaluated and he is aware of
this.
# ATRIAL FLUTTER - Not on rate control at baseline (due to
hypotension). NSR on admission and on telemetry monitoring.
Avoided nodal blockade given above syncope concerns. CHADs-2
score of 2. On anticoagulation and therapeutic on discharge with
an INR of 2.6.
# ___ - Baseline 1.2. Appeared volume depleted on admission with
notable orthostatic hypotension. IV fluids resulted in
improvement.
# HYPERTENSION - On terazosin. Resumed alpha-blocker on
discharge.
# BPH - Continue finasteride. Resumed terazosin on discharge.
# HYPERLIPIDEMIA - Not on statin medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor vehicle collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Yo M pt presenting s/p MVC. Restrained driver on highway
going 30 mph. Car totaled. all airbags deployed. pt
complaining of rib pain. transported by EMS. given 100 of
fentanyl.
Past Medical History:
HTN
DM
CAD
DVT
L leg bipass ___ ago
L rotator cuff ___ yrs ago
MI stents x2
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 97.7, 88, 22, 178/80, 99%
HEENT: Midface stable, ___, EOMI, no septal hematoma, no
hemotympanum.
Chest: GAEB, No chest wall tenderness
CV: RRR
Rectal: Normal rectal tone, no blood on glove
GU: No blood at the meatus
Ext: No step offs. No midline TTP.
Neuro: GCS 15, moves all 4 ext to command, sensation grossly
intact
Discharge Physical Exam:
Vitals: 98.1 PO144 / 73 R Lying 63 18 96 Ra
HEENT: ___, EOMI, MMM, throat clear, minor tenderness over low
cspine and upper tspine and paraspinal muscles
Chest: CTA ___, no adventious sound appreciated, equal chest
rise, mild tenderness over right thorax
CV: RRR, no MGR
Ext: No spinal step offs. right anterior knee contusion with
hematoma, full rom upper and lower extremities.
Neuro: GCS 15, moves all 4 ext to command, sensation grossly
intact
Pertinent Results:
Admission Labs:
==================
___ 01:49PM BLOOD WBC-6.7 RBC-4.81 Hgb-14.3 Hct-43.2 MCV-90
MCH-29.7 MCHC-33.1 RDW-12.9 RDWSD-42.1 Plt ___
___ 01:49PM BLOOD Neuts-67.2 ___ Monos-6.7 Eos-3.4
Baso-0.4 Im ___ AbsNeut-4.49 AbsLymp-1.47 AbsMono-0.45
AbsEos-0.23 AbsBaso-0.03
___ 01:49PM BLOOD ___ PTT-27.7 ___
___ 01:49PM BLOOD Glucose-200* UreaN-28* Creat-1.4* Na-144
K-4.2 Cl-108 HCO3-23 AnGap-13
___ 01:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:56PM BLOOD Glucose-208* Lactate-1.5 Na-142 K-3.9
Cl-111* calHCO3-23
Imaging:
==========
___ C-SPINE SCAN WITH CO
IMPRESSION:
1. No evidence of spinal cord or ligamentous injury.
2. No edema in the region of questioned fracture on recent
cervical spine CT
to indicate definite acute injury.
3. Multilevel degenerative changes as described, worst at C4-C5
and C5-C6
where there is severe spinal canal stenosis with indentation of
the ventral
spinal cord without cord signal abnormality. There is moderate
bilateral
neural foraminal stenosis at multiple levels as described above.
___ (SINGLE VIEW)
IMPRESSION:
Comparison to ___. Lung volumes are low. Normal
size of the
cardiac silhouette. No pulmonary edema. No focal parenchymal
abnormalities.
No pleural effusions. No pneumothorax. Mild elongation of the
descending
aorta.
___ (AP, LAT & OBLIQUE
IMPRESSION:
No evidence for fracture or joint effusion.
___ C-SPINE W/O CONTRAST
IMPRESSION:
Possible nondisplaced fracture involving the left anterior
tubercle at C5, but
no other evidence of fracture.
___ CHEST/ABD/PELVIS W/
IMPRESSION:
No evidence of acute intrathoracic or abdominopelvic abnormality
or injury.
Equivocal evidence for nondisplaced right anterior third rib
fracture.
___ HEAD W/O CONTRAST
IMPRESSION:
No evidence of acute intracranial abnormality. Specifically, no
large
territory infarction, hemorrhage, or calvarial fracture.
___ #3 (PORT CHEST O
IMPRESSION:
No evidence of acute cardiopulmonary disease or injury.
Discharge Labs:
================
___ 06:06AM BLOOD WBC-6.8 RBC-4.75 Hgb-14.1 Hct-43.3 MCV-91
MCH-29.7 MCHC-32.6 RDW-12.7 RDWSD-42.1 Plt ___
___ 06:06AM BLOOD Plt ___
___ 06:06AM BLOOD Glucose-185* UreaN-26* Creat-1.3* Na-143
K-4.5 Cl-108 HCO3-23 AnGap-12
___ 06:06AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Glargine 96 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: preadmission prescription
7. Lisinopril 30 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Sildenafil 50 mg PO PRN as needed
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6H :PRN Disp #*10
Tablet Refills:*0
4. Glargine 96 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: preadmission prescription
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. Lisinopril 30 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. HELD- Gabapentin 300 mg PO TID This medication was held. Do
not restart Gabapentin until advised by your PCP.
15. HELD- Sildenafil 50 mg PO PRN as needed This medication was
held. Do not restart Sildenafil until advised by your PCP.
16.cane
Cane for ambulation
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Collision
nondisplaced right anterior third rib fracture
C5 left anterior tubercle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, AP supine portable.
INDICATION: Trauma.
COMPARISON: None available.
FINDINGS:
Lung volumes are low. Within the limitations of technique, cardiac,
mediastinal and hilar contours appear within normal limits. There is no
pleural effusion or pneumothorax. Lungs appear clear. No displaced fracture
is identified.
IMPRESSION:
No evidence of acute cardiopulmonary disease or injury.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with mvc vs tree. *** WARNING *** Multiple patients
with same last name!// trama, mvc vs tree
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.9 cm; CTDIvol = 45.5 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are age-appropriate.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality. Specifically, no large
territory infarction, hemorrhage, or calvarial fracture.
Radiology Report
EXAMINATION: Cervical spine CT.
INDICATION: History: ___ with mvc vs tree. *** WARNING *** Multiple patients
with same last name!// trama, mvc vs tree
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 24.0 cm; CTDIvol = 22.8 mGy (Body) DLP = 548.8
mGy-cm.
Total DLP (Body) = 549 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no spondylolisthesis. Vertebral bodies are preserved in height.
On the left, at C5, there is an equivocal fracture across the anterior
tubercle (02:47). No other potential fractures are identified. There is no
dislocation. There is no bone destruction. Prevertebral soft tissues are not
cyst wall in.
The C4-C5 interspace is moderately narrowed. On the right there is mild
neural foraminal narrowing due to uncovertebral osteophyte formation.
Anterior osteophytes are moderate in size. Shallow posterior osteophytic
ridge slightly narrows the central canal. At C5-C6, interspace is mild to
moderately narrowed. There is a very shallow posterior osteophytic ridge.
Anterior osteophytes are medium in size. At C6-C7, interspace is mild to
moderately narrowed. A right paracentral posterior osteophyte very slightly
narrows the canal. There is mild right-sided neural foraminal narrowing due
to uncovertebral osteophyte formation.
Surrounding soft tissue structures are unremarkable. Visualized lung apices
appear clear.
IMPRESSION:
Possible nondisplaced fracture involving the left anterior tubercle at C5, but
no other evidence of fracture.
Radiology Report
INDICATION: History: ___ with mvc vs tree. *** WARNING *** Multiple patients
with same last name!// trama, mvc vs tree
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 9.0 s, 71.1 cm; CTDIvol = 23.9 mGy (Body) DLP =
1,695.7 mGy-cm.
Total DLP (Body) = 1,696 mGy-cm.
COMPARISON: No prior studies available for comparison.
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. A tiny
calcified lesion in the mediastinum (series 2, image 51) likely represents a
calcified sub hilar lymph node.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. 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:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. 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 hydronephrosis. Multiple bilateral subcentimeter hypodense
lesions are too small to characterize. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is distended with food contents. Small bowel
loops demonstrate normal caliber, wall thickness, and enhancement throughout.
The colon and rectum are within normal limits. The appendix is normal. There
is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis. Prostate is moderately enlarged.
REPRODUCTIVE ORGANS: Mild prostatomegaly with the prostate measuring 5.0 cm.
The seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild calcified and noncalcified atherosclerotic plaque is noted in the
abdominal aorta. Maximum axial dimension is 26 mm, corresponding to very mild
ectasia. A stent of the left common femoral artery is partially visualized
and appears occluded.
BONES: There is no definite acute fracture. Mild contour abnormality along
the course of the right anterior third rib is equivocal for a nondisplaced
fracture. No focal suspicious osseous abnormality. Mild degenerative change
of the lumbar spine worse at L5-S1.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of acute intrathoracic or abdominopelvic abnormality or injury.
Equivocal evidence for nondisplaced right anterior third rib fracture.
Radiology Report
EXAMINATION: MR ___ SCAN WITH CONTRAST
INDICATION: History: ___ with ? c5 fractureIV contrast to be given at
radiologist discretion as clinically needed*** WARNING *** Multiple patients
with same last name!// r/o c spine injury r/o c spine injury
TECHNIQUE: Routine noncontrast MRI of the ___.
COMPARISON: Cervical spine CT on ___
FINDINGS:
Alignment is normal. No edema is seen in the region of the questioned
fracture of the left C5 anterior tubercle seen on CT. Vertebral body height
and marrow signal is otherwise maintained. There is loss of normal T2 disc
signal and height at multiple levels, worst from C4-C5 through C6-C7. The
spinal cord appears normal in caliber and configuration. No evidence of
ligamentous injury. No prevertebral edema.
At C1-C2, there is no evidence of spinal canal narrowing.
At C2-C3, there is no evidence of spinal canal narrowing. There is mild
bilateral neural foraminal narrowing.
At C3-C4, a small posterior disc causes mild spinal canal narrowing with
slight effacement of the anterior thecal sac. Uncovertebral hypertrophy
causes moderate bilateral neural foraminal stenosis.
At C4-C5, a posterior disc osteophyte complex, facet arthropathy and
uncovertebral hypertrophy result in severe spinal canal narrowing with
indentation of the ventral spinal cord without definite cord signal
abnormality. There is moderate bilateral neural foraminal narrowing.
At C5-C6, a posterior disc osteophyte complex, facet arthropathy and
uncovertebral hypertrophy cause severe spinal canal narrowing with indentation
of the ventral spinal cord without definite cord signal abnormality. There is
moderate bilateral neural foraminal stenosis.
At C6-C7, a predominantly right-sided posterior disc osteophyte complex causes
mild spinal canal narrowing with effacement of the right anterior thecal sac
without cord deformity. There is moderate bilateral neural foraminal
stenosis.
At C6-C7, there is no significant spinal canal or neural foraminal stenosis.
The visualized paravertebral soft tissues are unremarkable.
IMPRESSION:
1. No evidence of spinal cord or ligamentous injury.
2. No edema in the region of questioned fracture on recent cervical spine CT
to indicate definite acute injury.
3. Multilevel degenerative changes as described, worst at C4-C5 and C5-C6
where there is severe spinal canal stenosis with indentation of the ventral
spinal cord without cord signal abnormality. There is moderate bilateral
neural foraminal stenosis at multiple levels as described above.
Radiology Report
EXAMINATION: Right knee radiographs, three views.
INDICATION: Query fracture.
COMPARISON: None.
FINDINGS:
Joint compartment spaces appear preserved in with. There is a medium-sized
ossific spur along the tibial tubercle in addition to a small superior
patellar spur. No joint effusion is appreciated. There is no evidence for
fracture, dislocation or lysis.
IMPRESSION:
No evidence for fracture or joint effusion.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ Hx of HTN, T2DM, CAD, MI, DVT's on coumadin, restained
driver, MVC vs tree,-LOC, with R sub costal pain with C 5 left anterior
tubercle fracture// PNX? Pulmonary contusion PNX? Pulmonary contusion
IMPRESSION:
Comparison to ___. Lung volumes are low. Normal size of the
cardiac silhouette. No pulmonary edema. No focal parenchymal abnormalities.
No pleural effusions. No pneumothorax. Mild elongation of the descending
aorta.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with Chest pain, unspecified, 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 | ___ is a ___ year old male with a Medical history
notable for Hypertension, Type 2 Diabetes, coronary artery
disease, myocardial infarction s/p one stent in ___, a history
of deep vein thrombosis, who presented as a restrained driver in
a Motor vehicle collision involving a tree. During the admission
his GCS was 15. It was found that he had a C5 left anterior
tubercle fracture as well as a non-displaced right anterior
third rib fracture, both of which did not necessitate surgical
management, as well as minor contusions, one of which was to his
right anterior knee which was associated with a small hematoma.
The day after admission he was cleared of his rigid neck brace
with an MRI showing no neck injuries that would necessitate the
use of a rigid collar. The MRI C-Spine incidentally revealed
multilevel degenerative changes worst at C4-C5 and C5-C6 where
there was severe spinal canal stenosis with indentation of the
ventral spinal cord without cord signal abnormality, moderate
bilateral neural foraminal stenosis at multiple levels. It was
determined that these findings could be further explored at the
appointment with Dr. ___ in ___ weeks when he would follow up
for the C5 fracture. At the time of discharge Mr. ___ was
recovering well, pain was controlled, he was ambulating,
breathing well and overall feeling well.
Acute Issues:
===============
# Motor Vehicle Collision:
Patient was admitted to the hospital after a MVC, was worked up
for a trauma, which revealed a C5 left anterior tubercle
fracture, a nondisplaced right anterior third rib fracture, and
contusions to the chest wall and right knee. At the time of
discharge Mr. ___ was recovering well, pain was
controlled, he was ambulating, breathing well and overall
feeling well.
# Non-displaced right anterior third rib fracture:
Patient was provided with pain relief and an incentive
spirometer which they used to good effect. At the time of
discharge pain was controlled, patient was breathing well. Pain
was mild to moderate with daily improvements.
# C5 left anterior tubercle fracture:
It was revealed during the trauma workup that the patient had a
fractured their C5 left anterior tubercle. Orthopedics evaluated
the injury and determined that the injury did not require
surgery. A soft neck brace was provided for comfort and the
patient was recommended to follow up with the orthopedics spine
clinic in ___ weeks with Dr. ___ at which time the soft brace
could be discontinued. Additionally it was incidentally found
that there was multilevel degenerative changes worst at C4-C5
and C5-C6 where there was severe spinal canal stenosis with
indentation of the ventral spinal cord without cord signal
abnormality, moderate bilateral neural foraminal stenosis at
multiple levels. It was determined that these findings could be
further explored at the appointment with Dr. ___ as they were
asymptomatic.
# Right Knee Contusion:
patient was found to have a right knee contusion and hematoma.
It remained stable with mild improvement during admission. Pain
was well controlled, ROM was full. Ambulation was improved with
the use a walker, but he was stable without a walker. At the
time of discharge patient was walking independently.
Chronic Issues:
================
# Hypertension: Stable on home meds
# Coronary Artery Disease: Stable on home meds
# Diabetes: stable on home meds
# Nicotine Addiction: Patient did not require nicotine
supplements |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Gantrisin
Attending: ___.
Chief Complaint:
Altered mental status, acute kidney injury, hyperkalemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ year old female with chronic kidney disease
(baseline 1.3-1.6), insulin-dependent diabetes, diastolic heart
failure (EF >55%), and dementia who was sent in from her nursing
home after she was noted to have altered mental status with
acute on chronic renal failure (creatinine 3.2, potassium of
5.7). Per the nurse taking care of her the day PTA, she was
having more difficulty eating than usual although she was still
drinking fluids, and she was developed a new cough with nasal
congestion. At baseline the patient is oriented x1-2, is
nonambulatory for the last ___ months, and is incontinent,
although she is able to express herself verbally. She has not
had fevers, abdominal pain, N/V, dysuria, or hematuria.
Of note, her dose of Lasix was recently increased to 40 mg daily
(___). She was started on lisinopril 25 mg daily on ___
but this was discontinued on ___. Outside labs show
potassium 5.7, Cr 3.4, BUN 153, albumin 2.5, WBC 13.7, HCT 30.0.
.
In the ED, initial vitals were: 97.8 65 111/41 16 100% 2L. On
exam, patient was awake, oriented x1, slow to respond, appeared
dry. Labs were remarkable for WBC count of 12.2, HCT of 31.8
(baseline high twenties), creatinine of 3.5, sodium of 131,
potassium of 5.8, phosphorus of 4.9. UA with urine lytes was
obtained. EKG showed sinus w/ peaked T wave. CXR showed
atelectasis with no acute process. Foley catheter placed.
Patient was given calcium gluconate 2gram iv, x1 amp D50, and
regular insulin 8 units iv at 1525 for potassium 5.8 (dysphagia
so not given kayexcelate) for hyperkalemia). Given 500cc normal
saline. Vitals on Transfer: Temp - 97.6 oral, HR - 70, RR - 16,
BP - 135/39, O2 Sat 100% 2lnc.
On the floor the patient was stable but having some difficulty
swallowing water.
Past Medical History:
DM (HbA1C 8.3% ___
Congestive Heart Failure, TTE in ___: EF >55%, mild-to-mod
aortic regurgitation, mild-to-mod mitral regurgitation
Paranoid schizophrenia
Urinary incontinence
Chronic cystitis
Dementia
HTN
Osteoporosis
Chronic renal failure, baseline Cr 1.5 (stage III)
Anemia, has refused colonoscopy in the past.
Hypercholesterolemia
Multiple GI bleeds managed conservatively, last in ___
requiring 3u pRBCs
ORIF left hip fracture ___ complicated by blood loss (Hct
25.9 1u pRBC, 1u FFP)
Social History:
___
Family History:
Per OMR, Unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0 BP: 118/62 P: 67 R: 20 O2: 99% 2L
General: Elderly woman, no acute distress, A&Ox1
HEENT: Sclerae anicteric, proptosis worse on left than right.
Oropharynx very dry with small amount of white material on
tongue; no exudate or erythema.
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Inspiratory crackles at left base, otherwise clear to
auscultation bilaterally. Poor inspiratory effort. No wheezes,
or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2. ___ holosystolic
murmur. No rubs or gallops.
Abdomen: Soft, non-distended. Large ventral hernia present,
tender to palpation, not reducible. Bowel sounds present, no
rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ DP pulses. Trace edema in ___ to
thighs bilaterally. No clubbing, cyanosis.
GU: Foley in place, filled with purulent fluid and frank blood.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 97.6, Tm: 98.6 BP: 134/52 (127-148/50-62) P: 92
(80-100) R: 18 O2: 98% RA
General: Elderly woman, no acute distress, A&Ox1-2
HEENT: Oropharynx very dry with small amount of dried blood on
tongue and hard palate.
Lungs: Bibasilar crackles, but otherwise clear to auscultation
bilaterally. Poor inspiratory effort. No wheezes, or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2. ___ holosystolic
murmur. No rubs or gallops.
Abdomen: Soft, non-distended. Large ventral hernia present,
tender to palpation, not reducible. Bowel sounds present, no
rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ DP pulses. Trace edema in BLE. L
arm with increased swelling.
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-12.2*# RBC-3.79* Hgb-9.9* Hct-31.8*
MCV-84 MCH-26.2* MCHC-31.2 RDW-14.6 Plt ___
___ 03:00PM BLOOD Neuts-84* Bands-1 Lymphs-10* Monos-5
Eos-0 Baso-0 ___ Myelos-0
___ 03:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 03:00PM BLOOD ___ PTT-26.1 ___
___ 03:00PM BLOOD Glucose-321* UreaN-136* Creat-3.5*#
Na-131* K-5.8* Cl-103 HCO3-16* AnGap-18
___ 03:00PM BLOOD Calcium-8.4 Phos-4.9*# Mg-2.3
___ 05:57PM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-9.7 RBC-3.72* Hgb-9.5* Hct-31.9*
MCV-86 MCH-25.5* MCHC-29.7* RDW-15.2 Plt ___
___ 07:30AM BLOOD Neuts-85.1* Lymphs-12.4* Monos-2.3
Eos-0.2 Baso-0.1
___ 07:30AM BLOOD Glucose-205* UreaN-52* Creat-1.5* Na-143
K-4.5 Cl-113* HCO3-23 AnGap-12
___ 07:30AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9
MICROBIOLOGY:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood Culture, Routine (Pending):
___ Blood Culture, Routine (Pending):
IMAGING
___ ECG: Sinus rhythm. Prominent voltage in leads I and aVL
for left ventricular hypertrophy. Low precordial lead voltage.
Compared to the previous tracing of ___ no diagnostic
interim change.
___ CHEST (PA & LAT): Frontal and lateral views of the chest
demonstrate low lung volumes accentuating cardiomediastinal
silhouette which is likely within normal limits. Minimal
tortuosity is present along the thoracic aorta, with arch
calcifications. There is mild peribronchial cuffing and
interstitial opacities which could represent atypical infection
in the appropriate clinical setting. There is no confluent
consolidation, pneumothorax, or pleural effusion. Small amount
of dependent atelectasis is present in the left base. Diffuse
osteopenia is present, allowing for which no compression
fracture is evident.
___ RENAL U.S.: The left kidney measures 10 cm. The right
kidney measures 9 cm. There is no hydronephrosis, stone, or
mass on the right. The left kidney demonstrates new moderate
hydronephrosis. The ureter is not well seen; however, within the
bladder, there is a 4.6 x 3.1 x 2.3 cm mildly echogenic
nonvascular mass, potentially the cause of obstruction. This
could represent a hematoma or conglomerate debris, versus mass.
A urinary catheter is in place. Also noted is a lateral
interpolar left renal cyst measuring 2.6 x 2.4 cm.
Medications on Admission:
ALENDRONATE - 70mg tablet: 1 tab PO weekly every ___
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tab by mouth once a
day
CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth every
___ and ___
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth daily
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 20 U sq twice daily (at 6:30am and 4:30pm)
LACTULOSE - 10 gram/15 mL Solution - 15 ml by mouth once a day
prn constipation
OLANZAPINE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime
INSULIN REGULAR HUMAN [HUMULIN R] - SSI
LANTUS 100 units/ml - Inject 20 units subq twice daily at 6:30am
and 4:30pm
Medications - OTC
ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth q4h prn
pain
CALCIUM CARBONATE - 500mg Tablet - 1 Tablet PO daily
VITAMIN D3 - 400 IU Tablet - 2 Tablets PO daily
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
SENNOSIDES [SENNA] - 8.6 mg Tablet - 2 Tablet(s) by mouth twice
daily
DULCOLAX 10MG SUPP - 1 SUPP daily prn constipation if senna
ineffective
FLEET ENEMA - 1 enema per rectum daiy prn constipation if
dulcolax suppository ineffective
?Oxycodone 2.5mg PO q6h prn pain
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Every ___.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three
times weekly, on ___.
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous twice a day.
7. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO once
a day as needed for constipation.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain.
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
11. Vitamin D3 400 unit Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day.
12. docusate sodium 50 mg/5 mL Liquid Sig: One (1) Tablet PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. Dulcolax 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation: If senna ineffective.
15. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Enema Rectal
once a day as needed for constipation: If dulcolax suppository
ineffective.
16. Regular Insulin Sliding Scale
BS ___ = 0 units sub-q
BS 201-250 = 2 units sub-q
BS 251-300 = 4 units sub-q
BS 301-350 = 6 units sub-q
BS 351-400 = 8 units sub-q
BS > 400 = CALL MD
17. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 11 days. Last dose on ___.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Urinary Tract Infection
Secondary Diagnosis
Acute Kidney Injury
Hyperkalemia
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
INDICATION: ___ female with altered mental status. Question
infectious process.
___.
FINDINGS: Frontal and lateral views of the chest demonstrate low lung volumes
accentuating cardiomediastinal silhouette which is likely within normal
limits. Minimal tortuosity is present along the thoracic aorta, with arch
calcifications. There is mild peribronchial cuffing and interstitial
opacities which could represent atypical infection in the appropriate clinical
setting. There is no confluent consolidation, pneumothorax, or pleural
effusion. Small amount of dependent atelectasis is present in the left base.
Diffuse osteopenia is present, allowing for which no compression fracture is
evident.
IMPRESSION: Peribronchial cuffing and interstitial opacities could represent
atypical infection although not specific.
Radiology Report
INDICATION: ___ male with stage III chronic kidney disease and
dementia presents with acute on chronic renal injury and urinary tract
infection.
___.
FINDINGS: The left kidney measures 10 cm. The right kidney measures 9 cm.
There is no hydronephrosis, stone, or mass on the right. The left kidney
demonstrates new moderate hydronephrosis. The ureter is not well seen;
however, within the bladder, there is a 4.6 x 3.1 x 2.3 cm mildly echogenic
nonvascular mass, potentially the cause of obstruction. This could represent
a hematoma or conglomerate debris, versus mass. A urinary catheter is in
place.
Also noted is a lateral interpolar left renal cyst measuring 2.6 x 2.4 cm.
IMPRESSION: New moderate left-sided hydronephrosis with a 4.6 x 3.1 cm soft
tissue within the posterior aspect of the bladder, potentially obstructing.
Differential considerations include hematoma, mass, or conglomerate
inflammatory debris. Recommend urology consult with possible cystoscopy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABN LABS
Diagnosed with HYPERKALEMIA, RENAL & URETERAL DIS NOS, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 97.8
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 111.0
dbp: 41.0
level of pain: 0
level of acuity: 2.0 | ___ yo F w/ DM II (on insulin), CKD III (baseline Cr 1.5), ___,
who presents from her nursing home with AMS ___ UTI, ___, and
hyperkalemia.
# AMS secondary to infection - Most likely secondary to UTI.
With treatment of UTI with antibiotic, mental status has
improved. Hyponatremia upon admission was thought to be possibly
contributory but this corrected and pt still not at baseline.
She was treated for her UTI per below.
.
# UTI - Pt w/ urinary tract infection due to E.Coli only
resistant to Ciprofloxacin and Ampicillin. Initially treated
with IV Ciprofloxacin prior to sensitivites returning, but then
was switched to Meropenem on ___. Antibiotics should continue
for a total of 14 days to treat for a complicated UTI given
frank pus that was draining from her foley, new moderate left
hydronephrosis and the 4.6cm mass in the bladder that was
concerning for debris. A heparin-dependent mid-line was placed
in pts left brachial artery for administration of antibiotics.
Her last dose of antibiotics will be ___.
.
# Acute on chronic kidney disease - Baseline Cr 1.5, but
elevated to 3.5 upon admission. FeUrea 19.65% indicating
pre-renal in etiology. Physical exam corroborates this finding
as she appeared clinically very dry. In addition, it was noted
that her lasix had recently increased from 40mg daily to 20mg
daily on ___, which may have contributed to her volume
depletion. This was held during the hospitalization given her
volume depletion and she was discharged on 20mg lasix daily as
it was believed that 40mg daily may be too much for her. Pt's
creatinine improved to baseline with volume repletion. Atenolol
was held during her hospitalization given her ___, but
re-started upon discharge. Renal ultrasound showed new moderate
left hydronephrosis with a 4.6 x 3.1 cm soft tissue mass within
the posterior aspect of the bladder, potentially obstructing.
However, given right kidney was unaffected (no hydronephrosis),
it would be unlikely for it to be affecting the creatinine.
.
# Hyperkalemia - Pt's K was 5.8 upon admission w/ peaked T waves
on EKG, and she was given calcium gluconate, insulin w/ dextrose
given, with repeat K 5.1 in the ED. Etiology likely secondary to
acute kidney injury. She was initiated on lisinopril 2.5mg daily
on ___ but this was discontinued on ___. Potassium
improved as kidney function improved.
.
# Hematuria - Likely due to cysititis, though could be due to
traumatic foley insertion as well. Unclear if 4.6cm mass in
bladder seen on renal ultrasound contributing. Foley
intermittently obstructed by clots, but cleared with irrigation.
Urine was clear and yellow by hospital day 3. Was seen by
Urology in-house, who didn't feel that urgent cystoscopy was
indicated and recommended follow-up as an outpatient in 3 months
for cystoscopy.
.
# Hyponatremia/Hypernatremia - Pt's Na 131 upon admission, which
is below pt's baseline. Unclear in etiology but since pt
appeared clinically dry, it is likely that pt was secreting ADH,
and her Na is lower in concentration because of increased water
absorption. Urine osmolality was consistent with this. Pt's
sodium improved with volume repletion. However, she developed
hypernatremia, likely secondary to normal saline administration
(in the attempt to volume resuscitate). She was then started on
free water, as her free water defecit was calculated around 3L.
Her sodium improved to 143 with free water repletion upon
discharge.
.
# Soft-Tissue Bladder Mass - Renal ultrasound on ___ showed
left kidney
with new moderate hydronephrosis and a 4.6 x 3.1 x 2.3 cm mildly
echogenic
nonvascular mass in the bladder. Urology was consulted and felt
that it was most likely inflammatory debris admixed with blood
clot within the bladder. Per Urology's consult note, she had a
negative cystoscopy as recently as 3 months ago and a negative
urine cytology as well. They recommended follow-up with Dr.
___ in the ___ clinic in 3 months with cystoscopy.
.
# Non-anion gap acidosis - Unclear in etiology though could have
been caused by administration of IVF. Her acidosis was likely
exacerbating (or causing) pts hyperkalemia. Pt was given D5W w/
3 amps bicarb to help correct the acidosis (while repleting
volume), and her acidosis slowly resolved.
.
# Chronic diastolic heart failure - Pt on lasix 40mg daily at
home, which was recently increased from 20mg daily. She did not
receive her dose on the day of admission and her lasix was held
throughout the admission. She did have trace BLE edema and
bibasilar crackles, but appeared volume down. It is likely that
40mg lasix daily is too large of a dose for this patient, and so
she will be discharged on 20mg lasix daily. Upon clinical
re-assessment, this may be re-titrated up as indicated.
.
# DM II - Pt's blood sugars ran high during the admission (even
before administration of D5W). However, when she was given D5W
for free water repletion, her blood sugars ran in the 200-300s
and so her lantus was increased to 22 units BID and her SSI
titrated up slightly. However, she was discharged on her home
lantus of 20mg BID and her home regular insulin sliding scale as
the D5W administration was likely contributing to her high blood
sugars while she was in the hospital.
TRANSITIONAL ISSUES
# Please continue Ertapenem once daily until ___
# Recommend f/u pending blood cultures
# Discharged pt on lasix 20mg daily (decreased from 40mg daily)
though this medication was held during admission given that she
was volume down. Can consider up-titrating as deemed necessary
for fluid overload.
# Would consider uptitration of lantus and/or SSI if blood
sugars continue to run high
# Pt was evaluated by Speech and Swallow in-house, who
recommended Honey-thick liquids, pureed solids, meds crushed in
applesauce, strict 1:1 supervision with all PO intake, NO STRAW
with liquids, TID oral care, and encouraged continued swallow
follow up to assess diet tolerance and consider further diet
advancement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Traumatic Subarachnoid Hemhorrhage.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo RHWF s/p fall down some stairs at a restaurant after
having a few cocktails. Has some recollection of the event. She
was admitted to the neurosurgery service for close monitoring.
Past Medical History:
PMHx: MS, GERD, Hypothyroid, Hx of craniotomy for aneurysm
clipping/wrapping by Dr. ___ in ___.
Social History:
___
Family History:
NC.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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.
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.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
PHYSICAL EXAMINATION ON DISCHARGE:
___: Alert and oriented x3. PERRL. EOMs intact. Face
symmetrical. Tongue midline. No pronator drift. Moves all
extremities ___. She has baseline numbness and tingling from her
MS.
___ Results:
CT Head without Contrast: ___
1. Study is limited by motion artifact and streak artifact from
prior
embolization coils.
2. Grossly stable known right frontal subarachnoid hemorrhage.
3. No new acute intracranial hemorrhage noted.
4. Postsurgical changes related to prior frontal craniotomy and
anterior
cerebral artery aneurysm clipping.
5. Stable right parietal scalp soft tissue swelling and
subcutaneous
emphysema, with skin staples, with no evidence of underlying
fracture.
Chest X-Ray: ___
1. No radiographic evidence of acute, displaced rib fracture or
pneumothorax.
2. 1.9 cm opacity in left upper hemi thorax, likely due to a
structure
external to the patient, although a discrete pulmonary nodule is
not excluded.
Chest X-Ray: ___
Previously-seen nodular opacity not appreciated on this exam.
Otherwise,
unremarkable exam.
Medications on Admission:
Betaseron, Omeprazole, Neurontin, Levothyroxine.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
Do not exceed 4gm acetaminophen in 24 hours.
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Hold for lethargy. Do not drive while taking this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN Disp #*28 Tablet
Refills:*0
5. Senna 17.2 mg PO HS
6. Outpatient Physical Therapy
Vestibular physical therapy. Please evaluate and treat.
Diagnosis: Right frontal SAH
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
INDICATION: ___ woman with history of anterior cerebral artery aneurysm status
post repair, now with traumatic subarachnoid hemorrhage. Evaluate for
intracranial hemorrhage stability.
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, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ outside noncontrast head CT.
FINDINGS:
This study is limited by motion artifact and streak artifact from aneurysm
clip and by mild motion degradation.
Minimal right parietal scalp soft tissue swelling and subcutaneous emphysema
is noted, with additional skin stables noted to be present. Postsurgical
changes related to prior frontal craniotomy and anterior cerebral artery
aneurysm clipping are noted.
Compared with the earlier CT head, there has been no change in the size or
appearance of the known right frontal subarachnoid hemorrhage (___). No
new acute intracranial hemorrhage detected. There is no evidence of large
territorial infarction, edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. There are periventricular and
subcortical lucencies, which may represent small vessel ischemic changes.
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. Study is limited by motion artifact and streak artifact from prior
embolization coils.
2. Grossly stable known right frontal subarachnoid hemorrhage.
3. No new acute intracranial hemorrhage noted.
4. Postsurgical changes related to prior frontal craniotomy and anterior
cerebral artery aneurysm clipping.
5. Stable right parietal scalp soft tissue swelling and subcutaneous
emphysema, with skin staples, with no evidence of underlying fracture.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with fall, with left sided chest pain, along
ribs // evaluate for abnormality
COMPARISON: None avail
FINDINGS:
There is no radiographic evidence of acute, displaced rib fracture or
pneumothorax.
Exam is somewhat limited by overlying external monitoring leads which obscure
fine detail. A vague 1.9 cm round opacity overlying the left second anterior
rib may potentially be due to a structure external to the patient and is not
well localized on the lateral view. Heart size is normal. Aorta is tortuous.
Lungs are clear except for relatively symmetrical biapical scarring.
IMPRESSION:
1. No radiographic evidence of acute, displaced rib fracture or pneumothorax.
2. 1.9 cm opacity in left upper hemi thorax, likely due to a structure
external to the patient, although a discrete pulmonary nodule is not excluded.
RECOMMENDATION(S): Repeat chest radiograph is recommended following removal
of external leads.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:11 AM, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with possible Lung nodule vs EKG lead //
Please remove all external leads
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
The lungs are well expanded and clear. Previously seen left lung nodule is
not seen on this exam. No pleural effusion is seen. Heart size is normal.
The mediastinal and hilar contours are unremarkable.
IMPRESSION:
Previously-seen nodular opacity not appreciated on this exam. Otherwise,
unremarkable exam.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: , SAH, Transfer
Diagnosed with Traum subrac hem w LOC of 30 minutes or less, init, Fall on same level, unspecified, initial encounter
temperature: 97.8
heartrate: 86.0
resprate: 16.0
o2sat: 95.0
sbp: 151.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | The patient was evaluated in the emergency department on the day
of admission, ___ and was admitted to the neurosurgery
service with a traumatic subarachnoid hemorrhage. She remained
neurologically intact. The patient underwent a CXR for
complaints of rib pain. The chest x-ray was concerning for a
possible left lung nodule versus artifact. Radiology recommended
repeating the chest x-ray.
On ___, the patient remained neurologically intact on
examination. She was evaluated by physical therapy.
On ___, the patient remained neurologically intact on
examination. She underwent a repeat chest x-ray which noted the
previously-seen nodule opacity is no longer appreciated on
repeat chest x-ray. She was seen by physical therapy. She
continues with headache and nausea, no vomiting. HA improved
during the day. PO intake was encouraged. She was started
prophylactic SQ Heparin at 8pm.
On ___, the patient remained neurologically intact. She
continues with HA, nausea, and dizziness but it is improved and
is tolerating POs and getting out of bed. Physical therapy has
recommended outpatient vestibular ___ and has provided
information on concussion. She was provided with information to
contact vestibular ___ and cognitive neurology for follow up.
Education on post mild-TBI symptoms and recovery was done with
her and her husband at the bedside. She was advised to follow-up
in the ___ clinic for staple removal from her
laceration. She may also follow-up with her primary neurologists
as well as in our ___ clinic with a ___. They have no
further questions at this time and she was discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lisinopril / Alfuzosin /
Heparin Agents / Hyoscyamine / Penicillins
Attending: ___.
Chief Complaint:
SOB, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o CAD, IVCD placement who presents with cough and SOB
over the last ___omplains of occasionally coughing
up phlegm that is increasingly red. Otherwise denites
fevers/chills/n/v but does endorse decreased appetite. Endorses
vibration from wheeze in chest with some SOB while roaming the
house, but denies chest pain, chest tightness/squeezing. Denies
rhinorrhea, rash, sick contacts. Feels he has phlegm caught in
his throat. Says he did get a flu shot.
.
In the ED the pt was found to have 97.9 90 146/94 18 100%RA. He
had a CXR demonstrating RML consolidation. Pt had an EKG showing
a Vpaced rhythm. He was given Levaquin 750mg IV and given PORT
score 78 and discomfort, patient was admitted for further
monitoring.
.
On the floor the pt was 97.3 150/60 94 20 98%RA. He was sitting
in bed somewhat uncomfortable complaining of a rattling sound
with breathing.
.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Syncope
s/p PPM placement in ___
CAD s/p stent placement in LAD in ___
Hypertension
Hypercholesterolemia
GERD
Arthritis
BPH
Hyponatremia
Tonsillectomy at the age of ___
S/p umbilical Hernia repair x2
Perforated small intestine repair ___
hemorrhoidectomy ___
Social History:
___
Family History:
both parents had CAD, his youngest sister has an arrhythmia and
both sisters with pacemaker
Physical Exam:
Admission exam:
VS - 97.3 150/60 94 20 98%RA
GENERAL - rattling breath sounds, A&Ox3, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP eryth
NECK - supple, no thyromegaly, no JVD, no carotid bruits,
submandibular LAD
LUNGS - expiratory crackles diffusely, scattered wheezes, esp in
RL/ML
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - mildly distended, slightly bulging flanks, ttp L
mid/upper abdomen
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
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
.
Discharge exam:
VS - 97.5 140/70 95 18 99%RA
GENERAL - A&Ox3, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP eryth
NECK - supple, no thyromegaly, no JVD, no carotid bruits,
submandibular LAD
LUNGS - very faint R lower/mid lobe crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - mildly distended, slightly bulging flanks, ttp L
mid/upper abdomen
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
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:
___ 03:45AM BLOOD WBC-7.1 RBC-4.09* Hgb-13.4* Hct-38.1*
MCV-93 MCH-32.7* MCHC-35.1* RDW-12.8 Plt ___
___ 03:45AM BLOOD Neuts-74.2* ___ Monos-4.7 Eos-1.9
Baso-0.6
___ 03:45AM BLOOD ___ PTT-25.5 ___
___ 03:45AM BLOOD Glucose-104* UreaN-14 Creat-1.0 Na-132*
K-4.3 Cl-97 HCO3-25 AnGap-14
___ 03:45AM BLOOD ALT-9 AST-18 CK(CPK)-69 AlkPhos-45
TotBili-0.7
___ 03:45AM BLOOD cTropnT-<0.01
___ 05:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.6
.
Micro
___ BCx pending ___ Urine legionella neg
___ sputum contaminated
.
___ ekg: The rhythm is one hundred percent atrial sensed,
ventricular paced rhythm at 96 beats per minute with frequent
ventricular premature beats. Compared to the previous tracing of
___ no other diagnostic interval change.
.
___ CXR: Left-sided pacemaker is noted with leads
terminating in the right atrium and right ventricle. Increased
opacification within the right lung with silhouetting of the
right heart border is concerning for right middle lobe
pneumonia. Opacification at the left lung base may represent
atelectasis. The cardiac silhouette is normal.
Medications on Admission:
Crestor 40mg daily
Omeprazole 20mg daily
Aspirin 325mg daily
Aleve BID
Naphcon-A
MVI
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days: Last day ___.
Disp:*2 Tablet(s)* Refills:*0*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing for 1 months.
Disp:*1 inhaler* Refills:*0*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aleve 220 mg Tablet Sig: One (1) Tablet PO twice a day.
8. naphazoline-pheniramine 0.025-0.3 % Drops Sig: Two (2) Drop
Ophthalmic QID (4 times a day) as needed for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with cough and blood-tinged sputum, evaluate
acute process.
COMPARISON: ___.
PA AND LATERAL CHEST RADIOGRAPH: Left-sided pacemaker is noted with leads
terminating in the right atrium and right ventricle. Increased opacification
within the right lung with silhouetting of the right heart border is
concerning for right middle lobe pneumonia. Opacification at the left lung
base may represent atelectasis. The cardiac silhouette is normal.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, SHORTNESS OF BREATH
temperature: 97.9
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 146.0
dbp: 94.0
level of pain: 0
level of acuity: 3.0 | ___ with h/o CAD, IVCD placement who presents with cough and SOB
over the last 3 days found to have RML pna.
.
# RML PNA: Patient presented with SOB, cough, hemoptysis found
to have RML PNA. The pt fit criteria for CAP, so was started on
Levofloxacin 750mg q24h. Pt was stable on RA, afebrile, without
leukocytosis throughout admission. Urine legionella was
negative, bcx pending at time of discharge. He received chest
___, nebs PRN. He was discharged on Levofloxacin 750mg PO daily
to complete a 5day course. He was also given a prescription for
albuterol MDI prn wheezing.
.
# Hemoptysis: Pt with blood tinged sputum likely related to RML
pna. HCT remained stable, pt oxygenated well on RA.
.
# Hyponatremia: Pt with hx of hyponatremia ___ ?polydipsia
reporting that he salts his water at home, p/w Na 132 increased
from previous admission. Stable.
.
# CAD: continued crestor, aspirin
.
# HTN: not on anti-htn medications, unclear why. Will follow-up
with PCP for ongoing outpatient management.
.
# Arthritis: home naproxen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefepime
Attending: ___
Chief Complaint:
Neutropenic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male receiving decitabine salvage for AML after no response
w/ ___ with refractory disease, subsequently placed on
salvage decitabine, currently C3D21, presenting with fever and
neutropenia.
No localizing symptoms. Reports low grade temp 99.6 several days
ago, with ___ episodes of diarrhea after uptitrating bowel reg
for consiptation but no abd pain or nausea/vomiting, and GI
symptoms have been completely resolved for ___ days now.
Continued monitoring temps and today had temp of 100.2 though
felt quite well but referred into ED given neutropenia. NO
dyspnea, cough, rhinorrhea, nasal congestion, rashes, dysuria,
headaches. PICC site w/o erythema or drainage per pt.
Note that during his admission for 7+3 in ___ he was
treated
for presumptive fungal pneumonia based on fungal markers and CT
chest appearance and remains on voriconazole; these markers
trended down as outpt since.
ED COURSE:
initial VS in ED 16:48 0 98.5 90 145/93 16 100% RA.CXR without
acute process. UA bland. Lactate 0.8 chem unremarkable. ANC 20.
Hct 22.9. Plts 25. INR 1.1. He was given vancomycin, meropenem,
and home voriconzole evening of ___. Blood and urine cultures
sent.
On arrival to the floor he has no complaints or symptoms other
than quite concerned that he misplaced his cellphone in the ED
but physically quite well.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR
Patient presented ___ with
progressive fatigue, pancytopenia and a bone marrow biopsy with
increased blasts with cytogenetics demonstrating trisomy 11
consistent with MDS evolving into AML. Patient received
induction
chemotherapy with 7+3 on ___. D14 marrow with persistent
disease and patient was started on decitabine salvage on
___.
- 7+3 ___
- Decitabine ___
- Decitabine ___
- Decitabine ___ 5 day course
PAST MEDICAL HISTORY:
- Hemmorhoids
Social History:
___
Family History:
Brother with pancreatic cancer. Father with prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.3 120/78 96 20 97%RA
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown, R PICC w/o erythema/drainage
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM:
VS: 98.0 ___ 100s-120s/70s ___ 97-100%RA
Weight: 151.2 lb
Gen: NAD, sitting comfortably on edge of bed.
HEENT: No JVD.
CV: RRR, S1 and S2, no m/r/g.
LUNGS: CTAB
ABD: Soft, NT/ND, BS+.
EXT: WWP, no edema.
NEURO: A&O, moving all extremities
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-0.6* RBC-2.61* Hgb-7.6* Hct-22.9*
MCV-88 MCH-29.1 MCHC-33.2 RDW-13.8 RDWSD-43.7 Plt Ct-25*#
___ 06:00PM BLOOD Neuts-3* Bands-0 Lymphs-94* Monos-2*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.02*
AbsLymp-0.57* AbsMono-0.01* AbsEos-0.00* AbsBaso-0.00*
___ 06:00PM BLOOD ___ PTT-25.2 ___
___ 06:00PM BLOOD Glucose-103* UreaN-19 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
___ 06:00PM BLOOD Calcium-8.9 Phos-4.4 Mg-2.3
___ 06:27PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-1.5* RBC-2.68* Hgb-8.0* Hct-24.1*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.2 RDWSD-43.5 Plt Ct-10*
___ 06:30AM BLOOD Neuts-33* Bands-0 Lymphs-61* Monos-6
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.50*
AbsLymp-0.92* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 06:30AM BLOOD ___ PTT-27.3 ___
___ 06:30AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-32 AnGap-10
___ 06:30AM BLOOD ALT-87* AST-53* LD(LDH)-196 AlkPhos-175*
TotBili-0.5
___ 06:30AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.4
MICROBIOLOGY:
___ 7:36 pm CATHETER TIP-IV Source: ___.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
___ 5:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING:
___ Chest X Ray (PA and Lateral)
No acute cardiopulmonary process.
___ MRI Pelvis with and without Contrast
1. Small intersphincteric cavity which contains hemorrhagic or
proteinaceous products with surrounding inflammation/phlegmon in
the low posterior anus, as described above. This is a somewhat
unusual abnormality, as it does not have a typical appearance of
a drainable abscess, nor is there a fluid-filled tract to
suggest a fistula. An underlying neoplasm cannot be completely
excluded. Recommend correlation with physical exam findings, or
any history of prior
perianal intervention.
2. Adjacent probable external hemorrhoid.
3. Enlarged prostate with evidence of BPH.
4. Trabeculated bladder, likely due to chronic outlet
obstruction.
RECOMMENDATION(S): The patient may benefit from a colorectal
surgery
evaluation for the inflammatory perianal process.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with AML presenting with low grade temperatures //
eval for infiltrate
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided PICC terminates in the low SVC without evidence of pneumothorax.No
focal consolidation is seen. No pleural effusion or pneumothorax is seen. The
cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: History of AML, in remission on Decitabine, presenting with
neutropenic fever and inflamed painful lesion on anus. Please evaluate for
abscess or fistula extending from area of anal inflammation
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: None.
FINDINGS:
In the very low anal sphincter, within the intersphincteric space, extending
from 5 o'clock to approximately 8 o'clock, there is a crescent-shaped focus of
high signal on the precontrast T1 weighted images (8, 52). This is most
compatible with hemorrhage or proteinaceous material within a tiny
intersphincteric cavity. There is surrounding nodular inflammation and
probably phlegmon involving the external sphincter. Additionally, the
inflammation and phlegmon involves the internal sphincter and likely the
mucosal surface of the anus in this region. The inflammation extends downward
to the adjacent skin and right gluteal cleft. This does not have the typical
appearance of a drainable abscess. There is no fluid filled tract extending
to the skin to suggest a patent fistula.
In this region of the low posterior anus, there is a also a small lobulated 8
x 8 mm left sided enhancing lesion (901, 40),which has the appearance of an
inflamed hemorrhoid.
There is mild edema along the right gluteal cleft, which is nonspecific. This
does not correspond to any abnormal enhancement. It is likely dependent
edema, or possibly reactive changes from the nearby inflammation/phlegmon
mentioned above.
The prostate gland is enlarged, measuring 3.6 x 5.4 x 4.9 cm. There is
evidence of BPH in the central gland. This signal is grossly normal, though
this exam is not tailored to evaluate the prostate gland. The bladder is
trabeculated, likely due to chronic outlet obstruction. There is no focal
thickening or evidence of a mass.
The rectum and intrapelvic bowel loops are within normal limits without focal
inflammatory changes. There is no free fluid in the pelvis. There is no
pelvic or inguinal lymphadenopathy. The imaged pelvic arterial vasculature is
normal without evidence of an aneurysm. The imaged pelvic veins are patent.
There are no concerning osseous lesions. Mild degenerative changes are noted
in the bilateral hips. Post-surgical changes are noted from prior hernia
repairs. The soft tissues are otherwise unremarkable.
IMPRESSION:
1. Small intersphincteric cavity which contains hemorrhagic or proteinaceous
products with surrounding inflammation/phlegmon in the low posterior anus, as
described above. This is a somewhat unusual abnormality, as it does not have
a typical appearance of a drainable abscess, nor is there a fluid-filled tract
to suggest a fistula. An underlying neoplasm cannot be completely excluded.
Recommend correlation with physical exam findings, or any history of prior
perianal intervention.
2. Adjacent probable external hemorrhoid.
3. Enlarged prostate with evidence of BPH.
4. Trabeculated bladder, likely due to chronic outlet obstruction.
RECOMMENDATION(S): The patient may benefit from a colorectal surgery
evaluation for the inflammatory perianal process.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line // new left PICC 51 cm ___
___ Contact name: ___: ___
IMPRESSION:
Since the radiograph of ___, a right PICC has been removed, and a left
PICC has been placed, terminating in the lower superior vena cava. No other
relevant change.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Neutropenia
Diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere
temperature: 98.5
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with AML refractory to 7+3 now
with no marrow evidence of disease after 3 cycles of decitabine,
who presents with neutropenic fever. He had diarrhea 3 days
prior to admission but otherwise no infectious symptoms. He was
found to have a perianal phlegmon and was seen by surgery but
did not require any intervention. He was treated with meropenem
and transitioned to ertapenem on discharge. He will continue on
a two week course of ertapenem and will follow up in clinic on
___.
# Neutropenic fever: Pt presented with low-grade temperature to
100.2. Pt was initially started on meropenem for neutropenic
fever and this was continued upon identifying a perianal
intersphincteric phlegmon seen on MRI pelvis. He was evaluated
by surgery, but not intervention was needed. Alternative source
was his right PICC (placed ___, which was therefore removed
on ___ and replaced ___. Culture of the PICC tip showed
no significant growth. He remained afebrile while on IV
meropenem for empiric treatment of his perianal phlegmon. On
discharge, he was transitioned to IV ertapenem for a two week
course.
# AML: Pt has AML that was refractory to 7+3. He is currently
undergoing evaluation for allo-HSCT. He was continued on home
prophylactic acyclovir, atovaquone, and voriconazole. He
received 5 days of decitabine (C4). He was discharged on C4D5.
# Mood: Given his depressed mood and relatively poor oral
intake, he was started on mirtazapine 7.5 mg PO QHS and
continued this on discharge.
# Insomnia: Continued home lorazepam. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / torsemide
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF with hx of rheumatic mitral valve disease with combined
mitral stenosis and mitral regurgitation, symptomatic for ___
Class III symptoms, complete heart block s/p PPM, chronic AF on
Coumadin, HTN presenting with nausea, vomiting, diarrhea, and
sudden onset abdominal pain. Patient states that she was woken
up
at 3 AM this morning with sudden onset abdominal pain, which is
10 out of 10, associated with nausea and nonbloody nonbilious
vomiting ×2. Patient also reports she has been having diarrhea
for the last couple of days.
In the ED, initial VS were 97.6 92 161/81 20 100% RA.
She received IV Zofran x 2, 4 mg IV morphine, 1000 mL NS.
CBC with WBC 4.8, H/H 9.8/33.2, Plt 256. BMP with Na 132, K 4.6,
Cl 86, HCO3 29, BUN 25, Cr 0.9. INR 4.4. Lactate 2.2. BMP with
trace leuk esterase and few bacteria. VBG 7.38/54/28.
CTA with patent abdominal aorta, cloelithiasis with
cholecystitis, small amount of ascites, and massive
cardiomegaly.
Upon arrival to the floor, the patient tells the story as
follows. She reports that she currently feels well. She denies
current abdominal pain, nausea, vomiting. She reports that at
approximately 3 AM on the day of admission when she woke up with
significant amount of vomiting. She feels like she vomited
___
times, without blood, mostly water. She endorsed epigastric
pain. She also endorses watery diarrhea, without blood. She
denies sick contacts or recent travel. She reports that she has
an ongoing history of difficulty swallowing, but she does not
know how long this has persisted for, but seems to be more
chronic. She reports that chronically she will eat food and
then
feel "like she needs to burp." She otherwise denies recent
fevers, chills, chest pain, shortness of breath, orthopnea
dysuria, worsening lower extremity edema.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Mild CAD
- HFpEF
- SSS s/p PPM ___, chronic atrial fibrillation
- Mitral valve stenosis s/p attempted mitral valvuoplasty
complicated by pericardial effusion
- Aortic valve stenosis/insufficiency
- Left sided grade 1 infiltrating ductal carcinoma s/p
lumpectomy
___
- GERD
- anxiety
- glaucoma
- Urethral stricture s/p dilatation
- Dysphagia
- s/p hysterectomy
Social History:
___
Family History:
No family history of premature coronary artery disease. Sister
had breast cancer.
Physical Exam:
Admission Exam:
VITALS: 97.9 PO 143 / 67 73 18 93 RA
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
Mucous membranes slightly dry
CV: Heart regular, + blowing systolic murmur best heard at the
apex
RESP: Lungs clear to auscultation with good air movement
bilaterally, no crackles, no wheezes
GI: Abdomen soft, non-distended, non-tender 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
PSYCH: pleasant, appropriate affect
Discharge Exam:
VITALS: T 97.6, HR ___, HR 110s/70, RR 18, SpO2 97% on RA
GENERAL: Alert and in no apparent distress
CV: Heart regular, holosystolic murmur over the apex 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.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
Pertinent Results:
Admission Labs:
___ 11:42AM BLOOD WBC-4.8 RBC-4.23 Hgb-9.8* Hct-33.2*
MCV-79* MCH-23.2* MCHC-29.5* RDW-20.4* RDWSD-57.2* Plt ___
___ 11:55AM BLOOD ___ PTT-54.2* ___
___ 11:42AM BLOOD Glucose-138* UreaN-25* Creat-0.9 Na-132*
K-4.6 Cl-86* HCO3-29 AnGap-17*
___ 11:42AM BLOOD ALT-13 AST-24 AlkPhos-89 TotBili-0.9
___ 11:42AM BLOOD Lipase-22
___ 09:47PM BLOOD Lactate-1.3
Discharge Labs:
___ 09:45AM BLOOD WBC-6.9 RBC-3.81* Hgb-9.1* Hct-29.9*
MCV-79* MCH-23.9* MCHC-30.4* RDW-20.8* RDWSD-58.4* Plt ___
___ 08:00AM BLOOD ___
Micro:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Imaging:
CT abdomen/pelvis, ___:
IMPRESSION:
1. Patent abdominal aorta and its branches. However, there is
moderate to
severe atherosclerotic calcification at the origin of the celiac
trunk, SMA,
and bilateral renal arteries. No bowel wall thickening seen.
No pneumatosis
or free air.
2. Cholelithiasis without definite acute cholecystitis.
3. Hepatic steatosis.
4. Small amount of ascites, may relate to third spacing.
5. Unchanged massive cardiomegaly.
US abdomen/pelvis with Doppler, ___:
IMPRESSION:
At least 50% stenosis of the SMA.
Moderate abdominal aortic atherosclerotic plaque.
Gastric emptying study, ___:
IMPRESSION: Normal gastric emptying, no gastric outlet
obstruction.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Furosemide 40 mg PO 4X/WEEK (___)
2. Rosuvastatin Calcium 10 mg PO QPM
3. Verapamil SR 240 mg PO Q24H
4. Warfarin 2.5 mg PO DAILY16
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Furosemide 80 mg PO 2X/WEEK (___)
8. Spironolactone 25 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN
indigestion
RX *alum-mag hydroxide-simeth [Advanced Antacid-Antigas] 400
mg-400 mg-40 mg/5 mL 30 mL by mouth TID PRN Disp #*1 Bottle
Refills:*0
2. Metolazone 2.5 mg PO TWICE A WEEK
Take on days ___ take Lasix 80 mg
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H UTI
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*9 Capsule Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth TID PRN Disp #*30
Tablet Refills:*0
5. Simethicone 40-80 mg PO QID:PRN indigestion
RX *simethicone 180 mg 1 capsule by mouth QID PRN Disp #*90
Capsule Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
7. Verapamil SR 180 mg PO Q24H
RX *verapamil 180 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
10. Furosemide 40 mg PO 4X/WEEK (___)
11. Furosemide 80 mg PO 2X/WEEK (___)
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Rosuvastatin Calcium 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Functional dyspepsia
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: DUPLEX DOPP ABD/PEL
INDICATION: ?chronic mesenteric ischemia
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CT examination from ___.
FINDINGS:
Moderate atherosclerotic calcifications and plaque are again demonstrated
throughout the abdominal aorta.
The celiac artery appears patent, with a peak systolic velocity of 200 cm/sec.
Normal waveforms are demonstrated.
The SMA demonstrates a peak systolic velocity of 383 centimeters/second with
spectral broadening, compatible with stenosis of at least 50%.
IMPRESSION:
At least 50% stenosis of the SMA.
Moderate abdominal aortic atherosclerotic plaque.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.6
heartrate: 92.0
resprate: 20.0
o2sat: 100.0
sbp: 161.0
dbp: 81.0
level of pain: 10
level of acuity: 3.0 | ACUTE/ACTIVE PROBLEMS:
# Abdominal pain, nausea, vomiting:
The patient presented with one day of nausea, vomiting,
diarrhea, possibly secondary to viral gastroenteritis, which
subsequently improved. She does have a longstanding history of
dysphagia which has been worked up in the past with ___ EGD
earlier this year. CT A/P was without acute abnormality. She had
no evidence of acute surgical problem,diverticulitis,
appendicitis, pancreatitis and no evidence of RP bleed or AAA.
Her chronic symptoms of post-prandial emesis and pain, early
satiety, and weight loss are concerning for gastric outlet
obstruction, malignancy, and chronic mesenteric ischemia.
Gastroenterology was consulted. They recommended a gastric
emptying study, which was normal.
Vascular surgery was consulted given the high peak velocities in
the celiac artery and SMA on abdominal ultrasound with Doppler.
However, they did not think the findings showed stenosis
significant enough to diagnose CMI. Most likely, these chronic
GI issues are secondary to functional dyspepsia. She was started
on a trial of omeprazole 40 mg daily. A outpatient GI consult
was placed for follow up after the PPI trial.
She was treated symptomatically with simethicone, ondasetron,
and GI cocktail.
# Supratherapeutic INR
The patient's daughter, ___, relays that she has had
trouble in the past with labile INR. Her INR on admit was 4.4
and only returned to therapeutic range (2.1) after holding
warfarin for 4 days. Her dose was reduced from warfarin 2.5 mg
to 2 mg daily. Perhaps her GI issues causing poor PO intake have
resulted in a relative vitamin K deficiency causing labile INR.
# Atrial fibrillation, sick sinus syndrome s/p PPM:
- Warfarin dose decreased as above
- Continue Metoprolol succinate 100 mg daily
# HTN - Her home verapamil was decreased from 240 mg daily to
180 mg daily due to low systolic BPs (in the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex
Attending: ___.
Chief Complaint:
Dyspnea
Reason for MICU transfer: Hypoxemia
Major Surgical or Invasive Procedure:
endotracheal intubation and mechanical ventilation
bronchoalveolar lavage
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of OSA on CPAP
and chronic joint pain who presents with shortness of breath.
She was admitted to the hospital on ___ for fevers, rash, and
joint pain. She underwent a rheum workup for her symtoms. CXR
revealed an atypical pneumonia and she was discharged on
levofloxacin and rheum follow up. She notes progressive dyspnea
for the past week despite levofloxacin which has now progressed
to dyspnea at rest. She has had a constant non-productive cough
for the past week, and denies hemoptysis. She endorses
substernal pain with cough, but not otherwise. She denies
orthopnea, fevers, chills, recent weight loss, change in
appetite. She denies pleuritic pain, recent travel, or sick
contacts.
Review of systems is otherwise negative for headache, vision
changes, abdominal pain, nausea, vomiting, diarrhea,
constipation, hematuria, melena/hematochezia. She feels that her
joint pain has improved in the past week.
Today she triggered for chest pain/dyspnea with hypoxia. She
reported chest tightness ___. She was initially on 91-95% on 3L
NC, declined to 84% on 3L NC and ultimately was 93% on a
nonrebreather. Tmax 100.5. Her chest tightness eventually
completely resolved within minutes. Prior to transfer she
received ceftriazone, azithromycin, vancomycin. She received
prednisone 60 mg x1 as well as Furosemide 20 mg IV x3.
On arrival to the floor VS: HR 105 BP 129/73 RR 28 92% 4L
Past Medical History:
PMHx: obstructive sleep apnea on CPAP, joint pain with high ESR
and CRP on steroids.
PSHx: lap band ___ years ago.
Social History:
___
Family History:
Mild obesity throughout family on both sides.
Mother died from lung cancer ___ years ago (also was a smoker)
Physical Exam:
ON MICU ADMISSION:
Vitals- T:99.1 BP:129/73 P:114 R:33 18 92% O2:4L
General: Alert, oriented, tachypneic, speaking in short
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse crackles bilaterally, diffuse intermittent
wheezing
CV: Tachycardic, no murmurs appreciated
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
Discharge exam:
afebrile, 96% RA at rest, 92% with ambulation. other VS normal
General: Alert, oriented, no distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: faint crackles left base, otherwise clear to ausculation
CV: RRR, normal S1, S2, no murmurs or rubs
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
Pertinent Results:
___ 09:10AM GLUCOSE-288* UREA N-12 CREAT-0.7 SODIUM-142
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 09:10AM CALCIUM-8.9 PHOSPHATE-2.8 MAGNESIUM-1.9
___ 09:10AM WBC-14.7* RBC-4.13* HGB-11.1* HCT-33.0*
MCV-80* MCH-26.8* MCHC-33.6 RDW-16.1*
___ 09:10AM PLT COUNT-362
___ 06:20AM cTropnT-<0.01
___ 12:00AM cTropnT-<0.01 proBNP-1896*
___ 03:28AM ___ PTT-33.7 ___
___ 06:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 06:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
DIAGNOSIS:
BRONCHIAL LAVAGE, RIGHT UPPER LOBE:
ATYPICAL.
Atypical bronchial cells, favor reactive.
___
CXR prelim IMPRESSION: New opacities predominantly in the right
middle lobe and right perihilar region concerning for multifocal
pneumonia; hemorrhage or drug reaction is less likely.
___ Chest CT
IMPRESSION:
1. Predominantly bilateral upper lobe ground-glass opacification
with smooth septal thickening, mediastinal and hilar
lymphadenopathy, and absence of associated nodules involving the
bilateral upper lobes. Distribution of abnormality considered in
conjunction with rapid development suggests pulmonary hemorrhage
(with a wide differential of causes including vasculitis or
collagen vascular disease), or atypical infection. Given
lymphadenopathy, which could be reactive in the case of the
former differential considerations, findings could also be
consistent with sarcoidosis.
2. Enlarged pulmonary arteries suggest pulmonary hypertension
___ ECHO
The left atrium is normal in size. The right atrium is
moderately dilated. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is dilated with normal free wall
contractility. 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. The estimated
pulmonary artery systolic pressure is normal. There is a very
small circumferential pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Borderline dilated left ventricular size with
preserved systolic function. No significant valvular disease.
Very small pericardial effusion.
___ CXR
Portable frontal radiograph of the chest demonstrates ET tube
ending 4 cm
above the carina. There are persistent severe diffuse
parenchymal opacities which could reflect a combination of
multifocal pneumonia and pulmonary edema. Moderate cardiomegaly
persists. No large pleural effusion or pneumothorax.
___ CXR
As compared to the previous image, the endotracheal tube is in
unchanged
position. The pre described severe bilateral parenchymal
opacities are
unchanged in extent and severity, but there slightly increased
radiodensity is caused by a lesser inspiratory volume. No new
parenchymal opacities. Moderate cardiomegaly persists.
___ CXR
As compared to the previous radiograph, there is no change in
appearance of the massive bilateral parenchymal opacities in the
lung parenchyma and a moderate to severe cardiomegaly. The
patient has been intubated. The course of the endotracheal tube
is unremarkable. The tip projects 4 cm above the carina. There
is no evidence of complications, notably no pneumothorax
___ CXR:
As compared to the previous radiograph, the patient has been
extubated. Areas
of atelectasis at the lung bases persist but the lungs are
substantially
better ventilated than on the previous image. Moderate
cardiomegaly without
overt pulmonary edema. No pleural effusions.
discharge labs:
___ RDW Plt Ct
___ 32.2 16.2 439
UreaNCreatNa KClHCO3
18 0.8 138___ 32
INR 1.2
hypersensitivity pneumonitis profile pending
A1C- 6
___ and ANCA negative
HIV negative
SPEP with MGUS IgG kappa 13% (10% last year, not significant
change), UPEP negative
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
___ 2:17 pm BRONCHOALVEOLAR LAVAGE RIGHT UPPER LOBE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___:
NEGATIVE for Pneumocystis jirovecii (carinii)..
COMBINED WITH SPECIMEN LAB# ___ ___.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 1:34 am SPUTUM Source: Endotracheal.
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. Fexofenadine 180 mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU BID
3. Lorazepam 2 mg PO HS
4. Ranitidine (Liquid) 150 mg PO BID
5. Sertraline 200 mg PO DAILY
6. TraZODone 300 mg PO HS
7. Levofloxacin 750 mg PO DAILY
8. Naproxen 500 mg PO Q12H
9. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
10. Calcium Carbonate 1250 mg PO DAILY
11. Clindamycin 1 Appl TP DAILY
12. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN skin irritation
13. IMPLANON (etonogestrel) 68 mg Other ASDIR
14. Multivitamins 1 TAB PO DAILY
15. phentermine 30 mg oral daily
16. Vitamin D 1000 UNIT PO DAILY
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
Discharge Medications:
1. Calcium Carbonate 1250 mg PO DAILY
2. Fexofenadine 180 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Lorazepam 2 mg PO HS
5. Sertraline 200 mg PO DAILY
6. TraZODone 300 mg PO HS
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff IH every four
(4) hours Disp #*1 Inhaler Refills:*2
8. Benzoyl Peroxide Gel 10% 1 Appl TP DAILY
9. Clindamycin 1 Appl TP DAILY
10. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN skin irritation
11. IMPLANON (etonogestrel) 68 mg Other ASDIR
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Azithromycin 500 mg PO Q24H Duration: 7 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
15. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
16. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply to shoulder daily
Disp #*30 Patch Refills:*0
17. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL ___ mL by
mouth every six (6) hours Refills:*0
18. Ranitidine 150 mg PO HS
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth HS Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
acute lung injury, hypoxic respiratory failure- unclear
etiology, possibly due to atypical pneumonia, aspiration
pneumonitis, and other autoimmune pulmonary disorders in the
setting of tobacco use (e.g. NSIP)
Secondary diagnoses:
OSA
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath. Evaluate for pneumonia.
COMPARISON: Chest radiographs ___ and ___.
TECHNIQUE: Upright PA and lateral radiographs of the chest.
FINDINGS: Again, there is elevation and tenting of the left hemidiaphragm
suggesting persistent atelectasis. There is new lace-like interstitial
abnormality in the right upper lung and new opacities in the right middle lobe
and perihilar region. Mild cardiomegaly is unchanged. The mediastinal and
hilar contours are normal. There is no large pleural effusion or
pneumothorax.
IMPRESSION: New opacities predominantly in the right middle lobe and right
perihilar region concerning for multifocal pneumonia; hemorrhage or drug
reaction is less likely.
Updated results were telephoned to ___ by ___ at 8:05 am,
___, 10 minutes after discovery.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with pneumonia, unclear rheumatologic disease
and possible new CHF, pulmonary edema, infectious PNA, atypical PNA or
vasculitis changes.
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images.
DOSE: 1304 mGy.cm
COMPARISON: Comparison is made to multiple prior chest radiographs most
recently dated same day
FINDINGS:
The thyroid gland is unremarkable.
No supraclavicular or axillary lymphadenopathy identified. Multiple
mediastinal lymph nodes are top-normal in size measuring up to 9 mm. A a right
hilar lymph node is enlarged measuring 14 mm. The pulmonary artery is enlarged
measuring 3.5 cm. Aorta is are unremarkable. Heart size is enlarged and with a
small physiologic pericardial effusion.
Airways are normal and patent to the subsegmental levels. Diffuse ground-glass
opacifications with smooth septal thickening ("crazy paving pattern"), are
located predominantly in the upper lobes with near complete lobar involvement
of right upper lobe and a more subpleural distribution in the left upper lobe.
No associated nodules identified. No pleural effusion present.
Limited assessment of the upper abdomen demonstrates no abnormality.
No suspicious lytic or blastic lesions identified. No superficial soft tissue
mass is identified.
IMPRESSION:
1. Predominantly bilateral upper lobe ground-glass opacification with smooth
septal thickening, mediastinal and hilar lymphadenopathy, and absence of
associated nodules involving the bilateral upper lobes. Distribution of
abnormality considered in conjunction with rapid development suggests
pulmonary hemorrhage (with a wide differential of causes including vasculitis
or collagen vascular disease), or atypical infection. Given lymphadenopathy,
which could be reactive in the case of the former differential considerations,
findings could also be consistent with sarcoidosis.
2. Enlarged pulmonary arteries suggest pulmonary hypertension.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with rapidly worsening hypoxia. // Please
assess for etiology.
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the pre-existing parenchymal opacities
have minimally decreased in extent and severity. However, the overall severity
is still high and distribution of the changes is very diffuse. Most likely is
a combination of multifocal pneumonia and pulmonary edema. Moderate
cardiomegaly. No larger pleural effusions. No pneumothorax.
Radiology Report
INDICATION: Dyspnea status post intubation.
COMPARISON: ___.
FINDINGS:
Portable frontal radiograph of the chest demonstrates ET tube ending 4 cm
above the carina. There are persistent severe diffuse parenchymal opacities
which could reflect a combination of multifocal pneumonia and pulmonary edema.
Moderate cardiomegaly persists. No large pleural effusion or pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxemia, intubated // eval for interval
change, tube placement
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, the endotracheal tube is in unchanged
position. The pre described severe bilateral parenchymal opacities are
unchanged in extent and severity, but there slightly increased radiodensity is
caused by a lesser inspiratory volume. No new parenchymal opacities.
Moderate cardiomegaly persists.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory failure // inubation
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, there is no change in appearance of
the massive bilateral parenchymal opacities in the lung parenchyma and a
moderate to severe cardiomegaly. The patient has been intubated. The course
of the endotracheal tube is unremarkable. The tip projects 4 cm above the
carinal. There is no evidence of complications, notably no pneumothorax
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recent hypoxic respiratory failure,
improving clinically with diuresis and antibiotics // please eval for
interval change
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has been extubated. Areas
of atelectasis at the lung bases persist but the lungs are substantially
better ventilated than on the previous image. Moderate cardiomegaly without
overt pulmonary edema. No pleural effusions.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 99.0
heartrate: 118.0
resprate: 24.0
o2sat: 88.0
sbp: 134.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with a history of OSA on CPAP
and chronic joint pain on steroids who presents with shortness
of breath, transferred to the ICU with worsening hypoxemia.
# Hypoxemia: The differential for Ms. ___ was broad, though
at this time hypersensitivity pneumonitis is high on the
differential given her CT scan findings and rather rapid
improvement while in the ICU. She was transferred on ___ and
on day of call out to the floor is saturating in the low to mid
___ on ___ NC. Sputum culture unremarkable, viral studies
negative, acid fast smear negative. She has a BAL which was not
consistent with eosinophilic pneumonitis. There was also
suspicion for a community acquired pneumonia vs viral infection
resulting in ARDS. She was maintained on the ventilator at low
tidal volumes after her BAL. She was treated for community
acquired pneumonia with ceftriaxone and azithromycin with plan
for continuing antibiotics until PCP follow up.
___ etiologies (Goodpastures, lupus, Wegeners,
polyarteritis) were considered, though ANCA and ___ were
negative and the patient had a normal UA and renal function.
Urine legionella negative. No evidence of PCP and HIV was
negative. Her CXR with bibasilar opacification was quite
discordant with her CT scan findings of predominantly upper lobe
ground glass opacification. Given this as well as an elevated
BNP an ECHO was obtained, but not suggestive of diastolic heart
failure. Other etiologies that were considered included acute
intersitial pneumonia (e.g. NSIP) and DAH, though unlikely in
the setting of rapid improvement. On extensive questioning the
patient does not appear to have any obvious exposures (avian,
gardening, occupational), though does have an extensive smoking
history. A hypersensitivity panel was sent given suspicion for
hypersensitivity pneumonitis. Given her improvement a lung
biopsy, which would provide more definitive information, was not
pursued. She will need a repeat CT scan in ___ weeks to monitor
for interval change, and will follow up with her PCP and
pulmonology in the coming weeks. Upon discharge, she was 92-94%
on RA with ambulation. She was encouraged to continue to
abstain from tobacco use, and will use a nicotine patch to help
with smoking cessation.
# Chest pain: Patient presented with substernal chest pain ___
in severity prior to transfer to the ICU. Cardiac enzymes
negative x3 and chest pain had resolved prior to ICU arrival.
She had no recurrence of her chest pain.
# Coagulopathy: Patient with elevated INR to 1.6 on admission to
the ICU from baseline 1.3. LFTs WNL. Most likely nutritional
exacerbated by antibiotics. No indication for reversal,
improving without intervention.
# OSA, moderate: Continued on CPAP
# Depression: Continued Sertraline
# Chronic insomnia disorder: Conitnued lorazepam 2mg and
trazodone
300mg qhs as prescribed in sleep clinic
# Hyperglycemia: Patient initially hyperglycemic on admission.
Likely steroid induced. Was monitored with Q4H fingersticks and
blood glucose normalized. A1c 6.0%
Sliding scale insulin discontinued as she was not requring it in
the ICU. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L Leg Swelling, Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH of cryptogenic cirrhosis who
presents with LLE rash and swelling. He was in his usual state
of health until 2 weeks prior to
presentation, when he developed left leg swelling and redness.
He presented to the ED for evaluation, and was felt to have a
cellulitis. He was given CTX x1 followed by 7d course of
cephalexin. He reports some improvement in redness and edema,
though continued to have significant symptoms. He was evaluated
by his PCP who did not prescribe additional abx, but treated him
with pain medication. He finished his antibiotics around 1 week
ago. Since stopping abx, he has noticed worsening ___ edema and
erythema, with increased pain with walking. He also notes chills
x2 weeks w/o recorded fever, mild dyspnea, and mildly increased
abdominal girth. He states that he had an ultrasound that did
not
show any increased fluid, but he isn't sure how that is
possible. He denies abdominal pain, nausea, vomiting, diarrhea,
headache, changes in vision, dysuria, constipation.
In the ED initial vitals: 98.1 93 127/106 18 98% RA
- Exam notable for: obese male, with ___ SEM, LLE > RLE, 2+
pitting edema to the knee and onto thigh, LLE with
circumferential erythema with violaceous center, no crepitance,
but some vesicles, medial L ankle with flaking desquamating
skin.
- Labs notable for: Hgb 12.9, Plt 94, INR 1.2
- Imaging notable for: CXR w/minimal pulmonary vascular
congestion, ___ US w/o DVT.
- Patient was given: vancomycin 1g, oxycodone 5mg x3,
acetaminophen 1g, TMP/SMX DS 2 tabs, cephalexin 500mg,
doxycycline 100mg, PO ascorbic acid, finasteride 5mg daily,
spironolactone 50mg, ursodiol 1500mg
- Vitals prior to transfer: 98.3 78 150/99 20 98% RA
Currently, patient states that he is feeling fine. Redness and
pain is about the same. States that Tylenol and oxycodone were
helpful.
REVIEW OF SYSTEMS: 10pt ROS (+) per HPI, all other ROS otherwise
negative.
Past Medical History:
- Cryptogenic cirrhosis (no h/o varices, no h/o HE)
- h/o L sided anterior uveitis
- Diverticulosis
- h/o colon polyp s/p polypectomy
- BPH
- h/o benign tumor of L wrist
Social History:
___
Family History:
- Father w/heart disease
- No family history of liver disease or autoimmune disease
Physical Exam:
==============================
EXAM ON ADMISSION
==============================
VS: ___ 1354 Temp: 98.5 PO BP: 145/67 R Lying HR: 78 RR: 19
O2 sat: 96% O2 delivery: Ra
GENERAL: well-appearing male in NAD, sitting up in bed
HEENT: mmm, EOMI
NECK: supple, no LAD
CARDIAC: rrr, no murmurs
PULMONARY: CTAB
ABDOMEN: normal bowel sounds, soft, nontender, nondistended,
with no fluid wave
EXTREMITIES: minimal hair growth beneath knees bilaterally. L
leg with large area of erythema and warmth below knee, with
pitting edema of foot. Limited ROM of ankle due to pain.
Sensation intact
==============================
EXAM ON DISCHARGE
==============================
VS: T 98, HR 72, BP 147/61, RR 17, 97%RA
GENERAL: well-appearing male in NAD, sitting up eating breakfast
CARDIAC: rrr, no murmurs
PULMONARY: CTAB
EXTREMITIES: L leg with large area of erythema and warmth below
knee, continuing to improve from prior, with pitting edema of
foot. erythema and tenderness on medial aspect of leg just
superior to ankle, with no palpable fluid collection. Limited
ROM of ankle due to pain,
though improved. Sensation intact. 2+ DP pulse
Pertinent Results:
=============================
LABS ON ADMISSION
=============================
___ 01:06PM BLOOD WBC-4.8# RBC-4.39* Hgb-12.9* Hct-38.7*
MCV-88 MCH-29.4 MCHC-33.3 RDW-15.1 RDWSD-49.2* Plt Ct-94*
___ 01:06PM BLOOD Neuts-54.4 ___ Monos-14.9*
Eos-5.2 Baso-0.6 Im ___ AbsNeut-2.60# AbsLymp-1.17*
AbsMono-0.71 AbsEos-0.25 AbsBaso-0.03
___ 01:06PM BLOOD ___ PTT-33.0 ___
___ 01:06PM BLOOD Glucose-67* UreaN-13 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-23 AnGap-13
___ 06:06AM BLOOD ALT-16 AST-32 AlkPhos-102 TotBili-1.5
___ 06:06AM BLOOD Lipase-59
___ 07:25AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6
___ 06:06AM BLOOD Albumin-2.5*
___ 07:20PM BLOOD Lactate-1.4
=============================
LABS ON DISCHARGE
=============================
___ 07:22AM BLOOD WBC-3.7* RBC-3.74* Hgb-10.9* Hct-33.5*
MCV-90 MCH-29.1 MCHC-32.5 RDW-15.4 RDWSD-50.9* Plt Ct-58*
___ 06:55AM BLOOD Glucose-106* UreaN-24* Creat-1.2 Na-144
K-4.7 Cl-108 HCO3-27 AnGap-9*
___ 06:55AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.8
=============================
MICROBIOLOGY
=============================
- ___ Blood cultures x2 - no growth
=============================
IMAGING
=============================
___ LLE ___:
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.
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.
___ CXR (pa and lat)
FINDINGS:
There is minimal pulmonary vascular congestion. No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen. Cardiac silhouette is mildly enlarged. Mediastinal
contours are unremarkable. Evidence of DISH is seen along the
thoracic spine.
IMPRESSION: Minimal pulmonary vascular congestion.
Cardiomegaly.
___ Ultrasound of LLE
FINDINGS:
Transverse and sagittal images were obtained of the superficial
tissues of the left ankle. There is diffuse soft tissue edema
and skin thickening,
particularly within the soft tissues of the medial ankle. No
fluid collection is identified.
IMPRESSION: Diffuse soft tissue edema within the left ankle
however no drainable fluid collection is identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. HydrOXYzine 50 mg PO BID:PRN itch
3. Spironolactone 50 mg PO DAILY
4. Ursodiol 1500 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. cod liver oil 1,250-135 unit oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Cephalexin 250 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp
#*14 Capsule Refills:*0
3. Sarna Lotion 1 Appl TP QID:PRN itch
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % 1 application
to skin 4 times a day Refills:*0
4. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice daily Disp #*28 Tablet Refills:*0
5. Ascorbic Acid ___ mg PO DAILY
6. cod liver oil 1,250-135 unit oral DAILY
7. Finasteride 5 mg PO DAILY
8. HydrOXYzine 50 mg PO BID:PRN itch
9. Spironolactone 50 mg PO DAILY
10. Ursodiol 1500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
# Cellulitis of left lower extremity
Secondary Diagnosis:
# Cryptogenic cirrhosis
# Anemia
# Thrombocytopenia
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 cryptogenic cirrhosis, LLE edema and exertional
dyspnea// (1) CXR- eval for acute intrathoracic process; (2) LLE Doppler- eval
for DVT
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
There is minimal pulmonary vascular congestion. No focal consolidation,
pleural effusion, or evidence of pneumothorax is seen. Cardiac silhouette is
mildly enlarged. Mediastinal contours are unremarkable. Evidence of DISH is
seen along the thoracic spine.
IMPRESSION:
Minimal pulmonary vascular congestion. Cardiomegaly.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with cryptogenic cirrhosis, LLE edema and exertional
dyspnea// (1) CXR- eval for acute intrathoracic process; (2) LLE Doppler- eval
for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: US LOWER EXTREMITY, SOFT TISSUE LEFT
INDICATION: ___ year old man with cellulitis of left leg, with increased
tenderness and erythema over medial aspect of leg close to ankle, possibly
evolving fluid collection// eval for fluid collection
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left ankle.
COMPARISON: None.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left ankle. There is diffuse soft tissue edema and skin thickening,
particularly within the soft tissues of the medial ankle. No fluid collection
is identified.
IMPRESSION:
Diffuse soft tissue edema within the left ankle however no drainable fluid
collection is identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg swelling, Rash
Diagnosed with Localized edema, Cellulitis of left lower limb, Dyspnea, unspecified
temperature: 98.1
heartrate: 93.0
resprate: 18.0
o2sat: 98.0
sbp: 127.0
dbp: 106.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ gentleman with a PMH of cryptogenic cirrhosis
who presents with LLE rash and swelling, consistent with
cellulitis.
# LLE Cellulitis:
Patient admitted with LLE swelling, pain, and erythema,
concerning for cellultis with underlying vascular insufficiency.
DVT ultrasound was negative. Given that he had not improved with
outpatient regimen, decision was made to admit for IV
antibiotics. Received IV vanc and ceftriaxone, which was then
narrowed to vanc. He began to improve symptomatically. He had no
fevers during the admission, and his white count was
consistently normal. Given increased pain proximal to the ankle,
an ultrasound was done to assess for a fluid collection, which
was negative for fluid collection. He was switched to PO
antibiotics on ___, and discharged home on ___ to complete a
14 day course of Keflex and Bactrim.
# CRYPTOGENIC CIRRHOSIS: Patient has a history of cryptogenic
cirrhosis, without history of varices, HE, ascites. His LFTs
were within normal limits on admission.
# ANEMIA: Hgb on admission near prior baseline.
- continue to monitor
# THROMBOCYTOPENIA: Plts ___ on admission, consistent with
prior baseline ___ splenomegaly (measured at 20.2 cm on last
check.) Remained stable during this admission.
===========================
TRANSITIONAL ISSUES
===========================
[] Patient was discharged with a prescription of an additional
week of Keflex and Bactrim, for a total of a 16 day course.
[] Patient has plan for vascular follow up on discharge. Suspect
that a significant portion of patient's slow healing time and
erythema may be secondary to vascular insufficiency
[] Would recommend cardiac/pulmonary workup given report of
dyspnea on exertion (i.e. echo, PFTS and possible stress test if
not completed recently)
# Code - Full
# Contact - Proxy name: ___
Relationship: Wife Phone: ___
Comments: Alternate: ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sub arachnoid hemorrhage
My legs keep giving out.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time:1130 ___
_
________________________________________________________________
PCP: Name: ___.
Address: ___, ___
Phone: ___
Fax: ___
HPI:
The history below is taken from the ED dashboard and confirmed
with the patient upon arrival to the floor.
___ w/ hx ETOH, multiple falls, chronic bronchitis, type II DM
who was transferred from ___ from ___
where pt is undergoing detox from alcohol and she presented with
weakness, decreased ability to ambulate and inability for self
care. Paperwork states that she needs a higher lever of care. Pt
has been drinking for the last ___ years since the death of her
husband per report. Patient recently discharged on ___ after
multiple facial fx and small frontal SAH after a fall. Patient
went home at that time began drinking again. Then day prior to
admission (___), patient had fall causing ecchymosis on left
lower leg, and was found down by neighbor. Her neighbor then
called the police and she was sent to ___ detox center.
She denies any head trauma at that time. She reports that she
has difficulty ambulating since her legs "give out" due to
tremors in all extremities. Pt reports generalized weakness
prior to fall but does not report a prodrome or cp/sob/___
associated with incidents. ___ then referred her to
___ given her difficulties with ambulation and self care.
With respect to her alcoholism, she drinks 1 pint vodka per day
and has history of withdrawal seizures and visual
hallucinations. Last drink was ___. Of note, patient reports
chronic cough with her continued smoking and chronic bronchitis.
She has had dyspnea with exertion for past two weeks. Patient
denies fevers, chest pain, nausea, vomiting, diarrhea, abdominal
pain.
Afebrile, tachycardic to 113
Diffuse ronchi
Ecchymosis on left knee
neuro exam wnl, A&Ox3
CT OSH ___: small 1 cm focus of SAH (acute) in left frontal
lobe sulcus, no midline shift or mass effect
UA - leuk esterase 500, WBC ___, Sq ___
WBC 5.65
Patient seen by Neurosurgery at 19:00 ___. Recommended no
need for CT neck, no antileptics needed, will not need
neurosurgery follow up.
In ER: (Triage Vitals:7 98.2 ___ 18 99% RA )
Meds Given: ativan 1 mg
.
PAIN SCALE: ___
ROS is notable for feeling shaking, clammy.
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [X] All Normal
[ ] Fever [ ] Chills [ +] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [x] All Normal
[ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [] All Normal
[+] Headache - since the fracture ___ [- ] Visual changes [
] Sensory change [ ]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
ALLERGY:
[- ]Medication allergies [ ] Seasonal allergies
[x]all other systems negative except as noted above
Past Medical History:
ETOH abuse- with history of withdrawal seizures
DM type II- diet controlled- boderline - not on meds
Chronic bronchitis
hyperlipidemia
Breast CA -- got chemo/XRT, and had lumpectomy ___ ago
Social History:
___
Family History:
Confirmed on admission on ___
Mother: brain aneurysm deceased
Father: COPD deceased
___ Aunt/Uncle: ___
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
PAIN SCORE ___
1. VS Tm T P BP RR O2Sat on ____ liters O2 Wt, ht, BMI
GENERAL: Elderly dishelvelled female. She looks much older than
her stated age.
Nourishment: at risk
2. Eyes: [] WNL
Pupils sluggishly responsive b/l
3. ENT [] WNL
[] Moist [X] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[X] Regular [X] Tachy [] S1 [] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X ]WNL
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
[X] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
High steppage gait with tremors but pt able to walk to BR with
one assist.
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
Tremors in upper and lower extremities
+ asterixis
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
+ Sweaty
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
Pertinent Results:
___ 07:40PM URINE HOURS-RANDOM
___ 07:40PM URINE GR HOLD-HOLD
___ 07:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:40PM URINE HOURS-RANDOM
___ 07:40PM URINE GR HOLD-HOLD
___ 07:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
--------------
137|104|20|161
3.9| 25|0.7
AST = 49
Lipase = 122
ALK and ALP WNL
--------------------
5.65/35\142
Images reviewed by author:
Heart size is normal. Mediastinal and hilar contours are
unremarkable.
Pulmonary vascularity is normal. Lungs are clear. No pleural
effusion or pneumothorax is seen. No acute osseous
abnormalities are visualized. A clip projects over the left
axilla.
IMPRESSION:
No acute cardiopulmonary process.
---------------
No head Ct images or report sent with patient's paperwork.
Medications on Admission:
None
Discharge Medications:
1. Diazepam ___ mg PO Q2H:PRN CIWA > 10
RX *diazepam 5 mg 1 tablet(s) by mouth every ___ hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Subarachnoid Hemorrhage
- Acute Alcohol Withdrawl
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY:
Altered mental status and rhonchi.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are unremarkable.
Pulmonary vascularity is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. No acute osseous abnormalities are visualized. A clip
projects over the left axilla.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH
Diagnosed with TRAUM SUBARACHNOID HEM, UNSPECIFIED FALL, ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN
temperature: 98.2
heartrate: 113.0
resprate: 18.0
o2sat: 99.0
sbp: 156.0
dbp: 103.0
level of pain: 7
level of acuity: 2.0 | ___ year old female with a heavy history of alcohol abuse c/b
withdrawal seizures, heavy tobacco use brought in after being
found on the ground and found to have SAH. Unable to go home due
to concerns of unsteadiness and alcohol withdrawal.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, confusion, visual disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history notable for
HTN, HLD, and ___ transferred from ___ after
presenting with headaches, visual disturbance, and confusion.
Ms. ___ son reports that she first reported a mild
right
parietooccipital headache two nights prior to presentation,
around which time she was noted to be slightly more confused
than
usual, having some inappropriate speech and some difficulty
finding her way around her home. By the next day, her symptoms
had somewhat progressed, prompting her family to contact her
PCP,
who recommended outpatient imaging. However, yesterday evening,
Ms. ___ was noted to have apparent visual disturbance,
reporting that she wasn't able to see a donut placed on a plate
in front of her; she similarly reported difficulty identifying
objects in space, though it is not clear to her family whether
this was more pronounced on either side. By this morning, her
confusion and headaches had continued to progress, prompting
presentation to ___, where ___ revealed a right
occipital IPH, resulting in transfer to ___ for further
evaluation. Ms. ___ family denies a prior history of
similar symptoms. Notably, Ms. ___ has been noted to
have
memory difficulties more so over the past ___ years, during
which
time she has become dependent in her IADLs while remaining
independent in her ADLs, allowing her to live with her daughter
at home.
Unable to directly confirm ROS but family denies recent reports
of focal weakness, sensory disturbance, dizziness, gait
disturbance, bowel or bladder incontinence, fevers, chills, or
rash. Ms. ___ had briefly reported some abdominal
discomfort in the past few days.
Past Medical History:
HTN
HLD
Hypothyroidism
Diverticulitis
OA
Social History:
___
Family History:
Notable for sister with cerebral aneurysm, otherwise negative
for
neurological disorders.
Physical Exam:
Admission physical exam:
Vitals: T: 97.8 HR: 76 BP: 144/102 RR: 21 SpO2: 98% RA
General: NAD
HEENT: NCAT, neck supple
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, not oriented to time or place.
Unable to provide history. Speech largely fluent in ___ per
family, though with perhaps some comprehension deficit vs.
marked
inattention. Follows, with encouragement, some axial and
appendicular commands, and perseverates on prior task. No
apparent dysarthria per family. ?Left neglect vs. hemianopia.
- Cranial Nerves: Pupils 3 to 2.5 mm ___, slightly corectopic OS.
Unable to participate in confrontational visual fields with
somewhat inconsistent BTT, but overall attends to examiner in
right hemifield but not left. Spontaneous EOMI. Subtle L NLFF
with reasonably symmetric activation. Hearing intact to
conversation. Tongue midline.
- Motor: Does not participate in confrontational examination but
able to provide sustained antigravity effort with all
extremities
as well as with intact proximal power in BUE and distal power in
BLE.
- Reflexes: Limited by impaired relaxation, but 3+ at the
patellae with crossed adductors.
- Sensory: Response to touch in all extremities.
- Coordination: No dysmetria on reaching for examiner's hand in
right hemifield bilaterally.
- Gait: Widened base, mildly unsteady.
Discharge physical exam:
___ ___ Temp: 98.0 Axillary BP: 109/63 HR: 94 RR: 18 O2
sat: 96% O2 delivery: RA
___ ___ Dyspnea: 0 RASS: 0 Pain Score: ___
General: lying in bed, in NAD
HEENT - ~1cm x 3cm area of erythema, no fluctuance or induration
noted on exam
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: awake, pleasant, does not answer questions
appropriately. Babbles in a mixture of ___ and ___. When
asked questions, will answer ___ words coherently and then say
non-sensical words. Her speech is soft, though no apparent
dysarthria.
- Cranial Nerves: spontaneous EOMI. Subtle L NLFF.
- Motor: moving all limbs spontaneously to antigravity, does not
participate in confrontational examination. Pushes examiner away
with good strength.
- Reflexes: 2+ patellar and 1+ Achilles bilaterally
- Sensory: withdraws to tickle equally in all extremities
Pertinent Results:
___ 06:35AM BLOOD WBC-6.8 RBC-3.62* Hgb-11.1* Hct-35.6
MCV-98 MCH-30.7 MCHC-31.2* RDW-12.9 RDWSD-46.1 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-28* Creat-0.8 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-10
___ 06:35AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
___ 01:36PM URINE RBC-22* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-1
___ 01:36PM URINE Blood-TR* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*
___ 01:36PM URINE Color-Yellow Appear-Cloudy* Sp ___
Imaging:
CTA head and neck (___):
IMPRESSION:
1. Evolving intraparenchymal hemorrhage in the right occipital
lobe, overall
similar in size when compared with the prior study obtained 5
hours earlier.
Similar mild regional edema and mass effect. No significant
midline shift.
2. No new intracranial hemorrhage or acute large vessel
infarct.
3. Patent circle of ___ without definite evidence of
arteriovenous
malformation, aneurysm, high-grade stenosis or occlusion.
4. Patent bilateral cervical carotid and vertebral arteries
without definite
evidence of stenosis, occlusion, or dissection.
5. Chronic lacunar infarcts in the anterior limb of the right
internal capsule
bilateral basal ganglia.
CT head w/o contrast (___):
IMPRESSION:
No substantial interval change in the right occipital lobe
intraparenchymal
hemorrhage compared to study from 12 hours prior. There is no
significant
mass effect or midline shift. No new intracranial hemorrhage.
US neck soft tissue:
IMPRESSION:
Targeted exam evaluating a palpable abnormality in the right
anterolateral
neck demonstrates no drainable fluid collection.
EKG:
Sinus rhythm with occasional premature ventricular
depolarizations
Minimal voltage criteria for LVH, may be normal variant
T wave abnormalities
When compared with ECG of ___ 05:41,
premature ventricular depolarizations are now present
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Rosuvastatin Calcium 10 mg PO QPM
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Omeprazole Dose is Unknown PO DAILY
5. TraZODone 25 mg PO QHS:PRN Sleep
6. Aspirin 81 mg PO DAILY
7. Donepezil 10 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID until ___
2. Omeprazole 40 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Rosuvastatin Calcium 10 mg PO QPM
7. TraZODone 25 mg PO QHS:PRN Sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with occipital bleed w/ surrouding edema. ? avm vs.
tumor// AMV?
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, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
2) Sequenced Acquisition 12.0 s, 12.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
602.1 mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.9 mGy (Body) DLP =
10.0 mGy-cm.
4) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 575.6
mGy-cm.
Total DLP (Body) = 586 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head dated ___ at 11:45
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is redemonstration of an evolving intraparenchymal hemorrhage in the
right occipital lobe measuring approximate 2.2 x 1.9 cm, stable since the
prior study obtained 5 hours earlier. There is mild regional edema and mass
effect including partial effacement of the regional cerebral sulci and
occipital horn of the right lateral ventricle. No significant midline shift
is present. There is no new hemorrhage or definite intraventricular
extension. There is no evidence of acute large territory infarction,. Focal
hypodensities in the anterior limb of the right internal capsule and bilateral
basal ganglia are noted, likely related to chronic lacunar infarcts. There is
prominence of the cerebral sulci and ventricles suggestive of involutional
changes in this age group.
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:
Moderate calcified atherosclerotic plaque in the bilateral carotid siphons
without high-grade stenosis. There is fetal origin of the left posterior
cerebral artery, a normal variant. The vessels of the circle of ___ and
their principal intracranial branches otherwise appear normal without
stenosis, occlusion, arteriovenous malformation or aneurysm formation greater
the right posterior communicating artery is not visualized and may be
hypoplastic or congenitally absent. Than 3mm. The dural venous sinuses are
patent.
CTA NECK:
Mild calcified atherosclerotic plaque of the aortic arch and origins of the
right innominate, left common carotid and left subclavian is present.
Bilateral carotid and vertebral artery origins are patent.
Mild calcified atherosclerotic plaque at the bilateral common carotid
bifurcations without high-grade stenosis. There is no evidence of internal
carotid stenosis by NASCET criteria.
Mild calcified atherosclerotic plaque the V4 segment of the left vertebral
artery without high-grade stenosis. The carotidandvertebral arteries and
their major branches are otherwise normal with no evidence of stenosis or
occlusion.
OTHER:
The visualized portion of the lungs demonstrate left apical scarring. The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Evolving intraparenchymal hemorrhage in the right occipital lobe, overall
similar in size when compared with the prior study obtained 5 hours earlier.
Similar mild regional edema and mass effect. No significant midline shift.
2. No new intracranial hemorrhage or acute large vessel infarct.
3. Patent circle of ___ without definite evidence of arteriovenous
malformation, aneurysm, high-grade stenosis or occlusion.
4. Patent bilateral cervical carotid and vertebral arteries without definite
evidence of stenosis, occlusion, or dissection.
5. Chronic lacunar infarcts in the anterior limb of the right internal capsule
bilateral basal ganglia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with R occipital IPH, evaluate for progression
of hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head dated ___
FINDINGS:
There is redemonstration of intraparenchymal hemorrhage within the right
occipital lobe measuring approximately 2.2 x 1.8 cm, previously measuring 2.2
x 1.9 cm on study from 12 hours prior (02:13). Mild adjacent edema is
unchanged. There is no significant midline shift or mass-effect. There is no
new intracranial hemorrhage.
Periventricular and subcortical white matter hypo densities are likely sequela
of chronic small vessel disease. There is prominence of the ventricles and
sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No substantial interval change in the right occipital lobe intraparenchymal
hemorrhage compared to study from 12 hours prior. There is no significant
mass effect or midline shift. No new intracranial hemorrhage.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old woman with small occipital CAA bleed// is there any
concern for induration or fluctuance on right anterolateral neck
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right neck.
COMPARISON: CTA neck dated ___.
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right neck.
Deep to the palpable area of concern, there is no drainable fluid collection.
IMPRESSION:
Targeted exam evaluating a palpable abnormality in the right anterolateral
neck demonstrates no drainable fluid collection.
RECOMMENDATION(S): If there is any concern for an intramuscular hematoma, an
MRI of the neck may be performed.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: 97.8
heartrate: 72.0
resprate: 20.0
o2sat: 97.0
sbp: 177.0
dbp: 94.0
level of pain: 3
level of acuity: 2.0 | ___ w/ hx of HTN, HLD, hypothyroidism, dementia transferred from
___ after presenting with headaches, visual disturbance,
and confusion.
#R occipital lobar IPH ___ CAA
Initial CT head shows R occipital IPH, which was stable on
repeat CT head. Given age, dementia, and cortical location,
likely etiology is cerebral amyloid angiopathy. Antiplatelets,
anticoagulants, and NSAIDs were held during hospitalization as
these medications increase risk of bleeding. They should
continue to be held as an outpatient as CAA predisposes patient
to hemorrhage. MRI was not completed as patient could not
tolerate exam; while GRE sequence on MRI would definitively
determine if patient has amyloid angiopathy, clinical picture
seemed consistent with amyloid such that information from study
not worth harm and distress to patient. She will need a repeat
MRI prior to stroke follow up, and evaluation for amyloid
angiopathy can be done at this point. MRI brain with and without
contrast (to look for underlying mass lesion, also on
differential) was ordered in OMR for ___ weeks prior to follow
up in stroke clinic.
#Agitation
Agitation was a significant issue during hospitalization,
treated with PRN medications including Ativan, olanzapine, and
Seroquel. The most effective PRN was Seroquel at low dose.
Patient was diagnosed with a UTI which was thought to be
contributing to some of this agitation.
#UTI
Patient was diagnosed with a UTI (UA checked ___ for
agitation), and was started on Bactrim DS for a 5 day course
(___). The reflexed urine culture was pending at time of
discharge.
#Urinary retention
Patient also had intermittent urinary retention, for which she
was straight-cathed. Intermittently.
#Dysphagia
Swallow evaluation deemed patient safe for pureed diet with
nectar thick and thin liquids. Continued outpatient follow up
for dietary progression is needed; coordinate this through PCP.
#Hypertension
Home metoprolol ER 50mg daily was transitioned to 12.5mg Q6H
while inpatient. This can be transitioned to ER on discharge,
and patient should follow up with PCP for very strict blood
pressure control. In CAA, hypertension predisposes patients to
intracerebral hemorrhage so strict blood pressure control <130
is imperative. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Vancomycin / Lidoderm
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
From the admission HPI in OMR:
Ms. ___ is a ___ with a history of autoimmune hepatitis,
mixed connective tissue disease, osteoporosis with multiple
compression fractures, and rectal cancer s/p APR and subsequent
metastatic colon cancer with ileostomy (in ___ with Dr. ___
p/w 1 day of abdominal pain at the stoma site and decreased
ostomy output. The patient's symptoms started this morning, and
she has experienced ___ constant abdominal pain concentrated at
the stoma site. She denies nausea or vomiting, but has had
anorexia due to the pain. She called her physician this morning,
who advised her to drink plenty of water. She last ate at around
10am, and has not been drinking water since that time. She
denies
taking any medicines for her abdominal pain. The oral contrast
for her CT scan aggravated her abdominal pain. She has not had
similar symptoms since her discharge following surgery in ___.
Past Medical History:
- remote HepB (positive anticore, positive
anti-surface) and no overt viral replication (negative surface
ag, negative VL)
- remote ___ infection
- distal rectal cancer s/p resection
- recurrent adenocarcinoma of transverse colon s/p complete
colectomy and end ileostomy ___ c/b SBO and ischemic stoma
requiring repeat surgery
- autoimmune hepatitis
- advanced osteoporosis
- multiple compression fractures s/p vertebro- and kyphoplasty
- remove history of active pulmonary TB ___ yrs ago
- history of CMV infection, EBV infection (After steroids
started) and equivocal toxo titers in past
- MCTD: various SLE/Sjogren's manifestations
- GERD
Social History:
___
Family History:
No family history of colon cancer or liver disease. No family hx
of cardiac death.
Physical Exam:
VS: AVSS
Gen: well appearing, NAD
HEENT: no lymphadenopathy, moist mucous membranes
Lungs: CTAB
Heart: rrr
Abd: soft, mildly tender, nondistended, stoma with good output
Extremities: wwp
Pertinent Results:
___ 01:50PM GLUCOSE-68* UREA N-26* CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-18* ANION GAP-17*
___ 08:52PM WBC-3.9* RBC-2.43* HGB-8.3* HCT-24.6*
MCV-101* MCH-34.2* MCHC-33.7 RDW-13.2 RDWSD-47.8*
___ 08:52PM ALBUMIN-3.2*
___ 08:52PM cTropnT-<0.01
___ 10:10PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:52PM GLUCOSE-89 UREA N-22* CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-23 ANION GAP-11
Medications on Admission:
Azathioprine 50 mg tablet. 2 tablet(s) by mouth daily
Hydroxychloroquine 200 mg tablet. 1.5 tablet(s) by mouth daily
1.5 tablets (300mg) daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*80 Tablet Refills:*0
2. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Anti-Itch (menthol/camphor)] 0.5 %-0.5 %
apply to affected area twice daily Disp #*1 Bottle Refills:*0
3. Simethicone 40-80 mg PO TID:PRN gas, bloating
RX *simethicone [Gas Relief] 80 mg ___ tab by mouth three
times daily Disp #*50 Tablet Refills:*0
4. AzaTHIOprine 100 mg PO DAILY
5. Hydroxychloroquine Sulfate 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
partial small bowel obstruction
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: ___ with autoimmune hepatitis, history of SBO s/p ostomy, here
with constipation and abdominal pain. Evaluate for small bowel obstruction,
liver changes from prior, diverticulitis, abdominal 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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 279 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: There is mild basilar atelectasis. There is no pleural effusion.
The heart size is within normal limits. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. 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. New since ___, there
are multiple loops of dilated loops of small bowel with air-fluid levels.
Dilated small bowel can be traced to a fecalized segment just proximal to the
ileostomy in the right lower quadrant. There is trace amount of free fluid in
the right lower quadrant around the dilated loops of small bowel. The large
bowel has been removed. Mild mesenteric edema noted involving the distal
segment of small bowel just proximal to the ileostomy.
PELVIS: The urinary bladder is decompressed and distal ureters are
unremarkable. There is pelvic descent. 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.
BONES: Patient is status post vertebral prostate E of T10 and L3. Compression
deformity at T11 and T12 are stable. Endplate irregularity of T2 is also
unchanged. Sclerotic area in the right side of the sacrum is unchanged from
prior exam. There is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: Aside from fat containing parastomal hernia, the abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. Small-bowel obstruction transitioning just proximal to the ileostomy. Trace
amount of mesenteric edema and free fluid in the right lower quadrant. No
drainable fluid collection. No abscess.
2. Unremarkable liver.
Radiology Report
INDICATION: ___ year old woman with h/o CRC s/p ileostomy ___, ___ p/w
partial SBO that was resolving but now having more pain.// looking for
ileus/obstruction
TECHNIQUE: Supine and upright views of the abdomen
COMPARISON: CT scan of the abdomen from ___.
FINDINGS:
There are multiple loops of dilated small bowel, slightly improved when
compared to the scout image from the recent CT scan of the abdomen. There is
no free air. An ileostomy is noted in the right lower quadrant.
Postprocedural changes are seen in the spine. The bones are osteopenic.
IMPRESSION:
Multiple loops of dilated small bowel, somewhat improved when compared to the
scout film from the recent CT scan dated ___.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified intestinal obstruction
temperature: 97.6
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 66.0
level of pain: 5
level of acuity: 3.0 | Ms ___ was seen in the emergency department for decreased
ostomy output and abdominal pain around the ostomy site. She
continued to have ostomy output, but was nauseated and unable to
take PO without pain. A CT scan was obtained that showed a
likely partial small bowel obstruction without abscess or
evidence of closed loop obstruction. She was admitted to the
colorectal surgery service for conservative management of the
partial SBO with bowel rest, fluids per IV, and pain management.
With this regimen, her pain was treated and her stoma output
increased to a normal level. At the time of discharge, she was
tolerating a regular diet, voiding spontaneously, had a
productive stoma, and was able to ambulate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Amoxicillin
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
___ EGD and colonoscopy
History of Present Illness:
___ w/ CAD s/p CABGx4 and LAD stent in ___ (last dose of
plavix ___, afib on coumadin, hx of sigmoid volvulus in
___ s/p sigmoidectomy, presenting from urgent care with
concern for GI bleed. The patient was in his usual state of
health, however, he reports some lightheadedness with standing
over the last few weeks. A few days prior to admission, on
___, he was on his exercise bike; after about ten minutes he
became diaphoretic and short of breath which is unusual for him.
Had INR checked yesterday, found to be 3.9. He tried to contact
his PCP, but instead went to urgent care, where here was found
to be orthostatic, with SBPs in the ___ upon standing. He
wasfound to have worsening ST depressions, with a troponin of
.04. He was transferred for further workup.
He reports that over the past few months he has noticed that
his bowel movements have been darker than usual, which he
describes as dark brown with a reddish tint around the stool. He
states that he wasn't sure if it was blood because he also takes
iron. He also reports some dark and tarry stools. He denies ever
having a GI bleed before, but reports that he was told in the
past he may have a stomach ulcer. He shares that he had the
sigmoidectomy in ___ and that since that time, his bowel
movements have never been the same. Her reports soft bowel
movements and episodes of fecal leakage every time that he eats
something
He otherwise denies syncope, chest pain, or chest pain with
exertion. Upon review of systems, his main concern is
"neuropathy." He reports he was told by his chiropractor that he
had neuropathy and that it may be a side effect of atorvastatin.
He reports bilateral numbness and tingling in his feet. He
denies muscle pain. He endorses palpitations which are chronic
for him and he associates with his atrial fibrillation. He
denies fevers, chills, nausea, vomiting, abdominal pain.
In the ED, initial vitals were: 98.2 62 145/84 19 100% RA
Labs notable for CBC of 15.6, H/H of 5.9/19.5, Plt 222. BMP
notable for Na 134, K 4.7, Cl 91, HCO3 21, BUN 40, Cr 1.3. UA
negative. Troponin negative x 1.
Patient was given 1L NS, pantoprazole 40 mg IV, .5 lorazepam,
and 2.5 mg vitamin K.
Vitals prior to transfer: 98.2 65 120/69 17 98% RA
On the floor, the patient appears well.
Past Medical History:
- CAD s/p 4 vessel CABG in ___ and LAD stent ___
- Afib on coumadin
- HTN
- hyperlipidemia
- Gout
- BCC (basal cell carcinoma) nose s/p excision
- Lumbar spinal stenosis
- OA (osteoarthritis)
- Gynecomastia
- Chronic kidney disease, stage III (moderate)
Past Surgical History:
- Bilat hip arthroplasty
- CABG ___
- Excision of basal cell CA on nose
- Cataract
Social History:
___
Family History:
No history of bleeding disorders in his family. Mother with
unknown cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.1 PO 114 / 68 R Lying 63 20 100 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, faint systolic murmur
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: alert, oriented, speech fluent, follows commands, ___
strength in hip flexion, plantar and dorsiflexion of bilateral
lower extremities
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 ___ 55-70 98-100%RA
General: alert, oriented, no acute distress
HEENT: MMM
Lungs: CTAB, no wheezes, rales, ronchi
CV: irregularly irregular, faint systolic murmur heard at heart
base
Abdomen: soft, NTND, NABS
GU: no foley
Ext: WWP, no c/c/e
Neuro: moving all extrems equally, gait normal
Pertinent Results:
ADMISSION LABS:
___ 08:20PM BLOOD WBC-15.6* RBC-1.87*# Hgb-5.9*# Hct-19.5*#
MCV-104*# MCH-31.6 MCHC-30.3* RDW-17.9* RDWSD-66.0* Plt ___
___ 08:20PM BLOOD Neuts-73.2* Lymphs-15.2* Monos-9.7
Eos-0.8* Baso-0.1 NRBC-0.1* Im ___ AbsNeut-11.38*
AbsLymp-2.36 AbsMono-1.51* AbsEos-0.13 AbsBaso-0.02
___ 08:50PM BLOOD ___ PTT-39.7* ___
___ 08:20PM BLOOD Glucose-121* UreaN-40* Creat-1.3* Na-134
K-4.7 Cl-99 HCO3-21* AnGap-19
___ 05:00PM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
___ 08:20PM BLOOD cTropnT-<0.01
___ 02:58AM BLOOD %HbA1c-5.6 eAG-114
PERTINENT LABS:
___ 08:20PM BLOOD cTropnT-<0.01
___ 01:34AM BLOOD CK-MB-3 cTropnT-0.11*
___ 07:25AM BLOOD CK-MB-3 cTropnT-0.09*
___ 06:45AM BLOOD Digoxin-0.4*
___ 02:58AM BLOOD %HbA1c-5.6 eAG-114
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-7.2 RBC-3.13* Hgb-9.0* Hct-30.3*
MCV-97 MCH-28.8 MCHC-29.7* RDW-16.0* RDWSD-56.0* Plt ___
___ 06:25AM BLOOD ___
___ 07:25AM BLOOD Glucose-96 UreaN-29* Creat-1.1 Na-142
K-4.1 Cl-105 HCO3-28 AnGap-13
___ 07:25AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
=
=
=
=
================================================================
STUDIES:
EGD ___
Findings:
Esophagus: Normal esophagus.
Stomach: Protruding Lesions Two non-bleeding polyps of benign
appearance and ranging in size from 2 mm to 3 mm were found in
the stomach body.
Duodenum: Normal duodenum.
Other findings: No old blood, fresh blood or active bleeding was
found.
Impression: Polyps in the stomach body
No old blood, fresh blood or active bleeding was found.
Otherwise normal EGD to third part of the duodenum
COLONOSCOPY ___
Findings:
Excavated Lesions Multiple non-bleeding diverticula were seen
in the throughout the right and left colon.
Other Red blood and blood clots were seen throughout the entire
colon. No site of active bleeding was seen. Due to significant
looping, the terminal ileum was not intubated. However, no fresh
or old blood was seen coming out of the terminal ileum. Due to
significant amounts of blood and poor prep, this colonoscopy was
insufficient for colon cancer screening.
Impression: Red blood and blood clots were seen throughout the
entire colon. No site of active bleeding was seen.
Due to significant looping, the terminal ileum was not
intubated. However, no fresh or old blood was seen coming out of
the terminal ileum.
Diverticulosis of the throughout the right and left colon
Due to significant amounts of blood and poor prep, this
colonoscopy was insufficient for colon cancer screening.
Otherwise normal colonoscopy to cecum
ECHOCARDIOGRAM ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
PMIBI ___
IMPRESSION: Mild, fixed inferolateral wall defect. No
reversible ischemic perfusion defects.
2. Mildly enlarged left ventricular cavity with mildly
decreased ejection
fraction of 45%.
=
=
=
=
================================================================
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Digoxin 0.125 mg PO DAILY
5. LORazepam 0.5 mg PO Q4H:PRN anxiety
6. Omeprazole 20 mg PO BID
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Warfarin 2 mg PO DAILY16
11. Sertraline 50 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Medications:
1. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Digoxin 0.125 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. LORazepam 0.5 mg PO Q4H:PRN anxiety
9. Omeprazole 20 mg PO BID
10. Sertraline 50 mg PO DAILY
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
12. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
13. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Lower GI bleed
Acute blood loss anemia
Secondary
Atrial fibrillation
Bradycardia
Nonsustained ventricular tachycardia
Coronary artery disease s/p CABG
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with Afib on Coumadin w/ GIB now off Coumadin and
s/p capsule endoscopy with concern for retained capsule. // Lodged capsule
from capsule endoscopy
TECHNIQUE: AP of the abdomen
COMPARISON: ___
FINDINGS:
Sternotomy wires are noted. Mediastinal clips are noted.
There are no abnormally dilated loops of large or small bowel.
Foreign body projects over the left iliac wing, correlate with history of
capsule
Bilateral hip arthroplasties.
Large amount of stool throughout the colon.
There is a dilated loop of large bowel in a left lower quadrant which is
likely the sigmoid colon
This preliminary report was reviewed with Dr. ___
radiologist.
IMPRESSION:
Large amount of stool within the colon.
Dilated loop of large bowel in a left lower quadrant is likely sigmoid colon
Foreign body projects over the left iliac wing, correlate with history of
capsule ingestion
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ man with history of atrial fibrillation off Coumadin
with flattening of the nasolabial fold. Evaluate for hemorrhagic or embolic
stroke.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
2) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 127.7 mGy (Head) DLP =
63.9 mGy-cm.
3) Spiral Acquisition 6.7 s, 21.5 cm; CTDIvol = 30.7 mGy (Head) DLP = 661.5
mGy-cm.
Total DLP (Head) = 1,573 mGy-cm.
COMPARISON: ___ and ___, noncontrast head CT.
FINDINGS:
Examination is limited by streak artifact from dental amalgam.
CT HEAD WITHOUT CONTRAST:
There is chronic left basal ganglia/internal capsule infarct, unchanged.
There is no evidence of acute large territorial infarction, hemorrhage, edema,
or mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Atherosclerotic vascular calcifications are noted of
bilateral vertebral and cavernous portions of internal carotid arteries.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The right A1 segment is hypoplastic, with the right A2 sharing common origin
with the left A2. There is severe narrowing of the V4 segment of the right
vertebral artery secondary to atherosclerotic calcification (06:50). There is
moderate narrowing of the V4 segment of the left vertebral artery secondary to
atherosclerotic calcification. There is severe narrowing of the cavernous
segment of the right internal carotid artery secondary to atherosclerotic
calcification (6:74). There is also narrowing of the ophthalmic segment of
the left internal carotid artery secondary to atherosclerotic calcification.
Irregularity of P2 and distal branches of bilateral posterior cerebral
arteries are also noted. The vessels of the circle of ___ and their
principal intracranial branches appear grossly patent without occlusion, or
aneurysm. The dural venous sinuses are grossly patent. The right transverse
venous sinus is asymmetrically hypoplastic.
IMPRESSION:
1. Examination is limited by dental amalgam streak artifact.
2. No acute intracranial abnormality including acute large territorial infarct
or hemorrhage.
3. Severe narrowing of the V4 segment of the right vertebral artery and
bilateral intracranial internal carotid arteries secondary to atherosclerotic
calcification.
4. Moderate narrowing of the V4 segment of the left vertebral artery.
5. Irregularity of P2 and distal branches of bilateral posterior cerebral
arteries.
6. Chronic left basal ganglia/internal capsule infarct.
Radiology Report
INDICATION: ___ with GIB and constipation, s/p capsule study // assess for
retained capsule, previously seen on KUB ___
TECHNIQUE: Supine radiographs of the abdomen were performed.
COMPARISON: Radiographs of the abdomen from ___.
FINDINGS:
There is redemonstration of dilation of the sigmoid colon, not significantly
changed compared to prior radiographs from ___. The more proximal
colon is normal in caliber with a moderate amount of scattered stool. No
dilated loops of small bowel are seen. The presence of free intraperitoneal
air is difficult to assess on these supine radiographs.
Bilateral hip prostheses are partially imaged. There are multilevel spinal
degenerative changes and scattered enthesopathy of the pelvis.
The capsule endoscope appears to have passed since the prior study.
Sternotomy wires and mediastinal clips are noted.
IMPRESSION:
1. Redemonstration of dilation of the sigmoid colon, not significantly
changed compared to prior radiographs from ___. Normal caliber
more proximal colon with a moderate amount of scattered stool.
2. No evidence of small-bowel obstruction.
3. Interval apparent passage of the endoscopic capsule.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Abnormal EKG
Diagnosed with Anemia, unspecified
temperature: 98.2
heartrate: 62.0
resprate: 19.0
o2sat: 100.0
sbp: 145.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ yo M with history of CAD s/p CABGx4 and
LAD stent in ___ (last dose of Plavix ___, Afib on
warfarin, and sigmoid volvulus in ___ s/p sigmoidectomy, who
initially presented with bright red blood per rectum.
# Anemia: presented with H/H of 5.9/19.5 in setting of INR 5.5.
He was transfused with 6U pRBCs and resulting H/H stabilized.
Chronicity was unclear as patient reported long history of dark
stools, particularly in the past few months. He underwent EGD,
colonoscopy, and capsule endoscopym, which did not identify an
active source of bleeding. Most likely cause of bleed is
diverticular given known extensive diverticulosis. His warfarin,
aspirin, and antihypertensive medications held initially and
ultimately were restarted once H/H was stable and there were no
signs of bleeding.
# Atrial fibrillation/supratherapeutic INR/bradycardia: Patient
with a history of atrial fibrillation, on digoxin, and
anticoagulation with warfarin. Admission INR of 5.5 in the ED
and given 2.5mg vitamin K in ED, additional 5mg IV, and FFPs
with reduction of INR to 1.4. Warfarin was restarted after
bleeding resolved. Home digoxin was held as patient developed
bradycardia to ___ on telemetry, with normal BP and no symptoms.
He may need pacemaker placed as outpatient. He would also like
to discuss ablation, cardioversion, or alternative
anticoagulants with his cardiologist.
# Non-sustained ventricular tachycardia | Troponin elevation:
Patient with monomorphic beats of VT on tele appearing beginning
___, none exceeding 9 beats. This was associated with an
elevated troponin to 0.11. Given concern for new ischemic event
and/or new CHF, he underwent echocardiogram and pMIBI. This
showed EF 50-55% with old fixed inferolateral defect and no
reversible defects. He will follow up with his outpatient
cardiologist Dr. ___ consideration of event monitor
and further management.
# Asymmetric facial exam: Nasolabial asymmetry with mild left
flattening noted on exam, but neither patient nor wife notice
changes. No other focal deficits detected on exam. CTA head w/wo
con negative.
# ___ on CKD: Resolved. Admission Cr of 1.3, up from a baseline
of 1.0 in ___, likely related to hypovolemia given blood loss.
Now downtrended to baseline.
# Possible neuropathy: Patient reports lower extremity
neuropathy with numbness and tingling but also reports weakness
and stiffness. Physical exam inconclusive. HbA1c was normal. OMR
indicates a diagnosis of lumbar stenosis, but no spinal imaging
available in our system. ___ be mistaking symptoms with
osteoarthritis. He has some complaints of his symptoms during
this admission, feels may be improving with gabapentin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"i'm agitated"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ longstanding ETOH Dependence, and depression presenting to
ED intoxicated and w/ SI. Patient took ___ mg ibuprofen w/
intention to "end it all". He had been staying in hotel, hotel
staff
noticed that he was not leaving room x several days, ordering
wine, and drinking heavily ___ boxes of wine daily, with ___ of
whiskey, due to stress at work.
Has 1 prior detox ___ in ___, but multiple withdrawal
seizures
Per psych's report, "reports ___ yr of low mood, isolation,
anedonia, no supportive relationships, in the context of
sobriety. Reports first
experienced SI w/ plan to od on ibuprofen 1 week ago, did not
act
on it. Although he reports taking NSAIDS today, he endorsed 3
days of dark stool, no frank blood. Recent history emesis but
no hematemesis. In ED, 3L fluids, valium 10mg, protonix, Guaiac
neg, thiamine, and MVI.
On arrival to the MICU, vitals were 125/81, resp 22, 116 BPM,
afebrile
Review of systems:
+ mild generalized HA, lightheadedness, abdominal pain.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Has low grade HA and lightheadedness. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation. , abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-depression
-previous SI
-EtOH dependence
Social History:
___
Family History:
Non contributory. No history of alcohol abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: anxious appearing
HEENT: atraumatic, normocephalic. Nystagmus, PERRLA.
Neck: No lymphadenopathy
CV: No MRG, regular rate
Lungs: CTAB
Abdomen: mild diffuse tenderness. No guarding or rebound
tenderness
GU: deferred
Ext: WWP
Neuro: Mental status: AAOx3, clear speech without aphasias or
anomias, no paraphasic errors. Attention intact. ___ words at 5
minutes. CNII-XII intact w/ mild lateral beating nystagmus.
+past pointing and tremor R>>L. No dysdiodokokinesias. Reflexes
normal. No ssensory deficits. Gait deferred. Normal heel to
shin.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.6 110/68 68 18 100%RA
General: Lying in bed comfortably, appears comfortable
HEENT: EOMI, no nystagmus noted, PERRL, moist mucous membranes.
Neck: No lymphadenopathy
CV: No MRG, regular rate
Lungs: CTAB
Abdomen: mild LLQ/RLQ tenderness. No guarding. Soft and
nondistended.
Ext: WWP
Neuro: AAOx3, answering questions appropriately. No tremor. Gait
deferred.
Pertinent Results:
IMAGING:
___ Imaging LIVER OR GALLBLADDER US
The hepatic echotexture appears within normal limits. No focal
nodules or masses are identified within the hepatic parenchyma.
There is no intra or extrahepatic biliary ductal dilation. The
portal vein is patent with flow in the appropriate direction.
Common hepatic duct measures 2 mm. The gallbladder is
nondistended and contains no stones. The mildly thick-walled
appearance of the gallbladder could relate to partial
distention. There is no evidence of pericholecystic fluid or
wall edema. Imaged portion of pancreas appears within normal
limits with portions of the pancreatic tail obscured by
overlying bowel gas. The right kidney measures 11.6 cm. The
left kidney measures 9.1 cm and is located in the pelvis. No
stones, masses, or hydronephrosis identified in either kidney.
The spleen measures 11.5 cm. There is no ascites. Imaged
portions of the abdominal aorta and IVC are normal in caliber.
Essentially normal right upper quadrant ultrasound. A mildly
thick-walled appearance of the gallbladder could relate to
underdistention and there are no findings to suggest
cholelithiasis or cholecystitis. No biliary dilation.
Incidental note of a pelvic left kidney.
___ 01:55PM BLOOD WBC-8.4 RBC-5.33 Hgb-17.0 Hct-49.8 MCV-94
MCH-31.9 MCHC-34.1 RDW-14.7 Plt Ct-94*
___ 09:05PM BLOOD WBC-4.3 RBC-4.52* Hgb-14.3 Hct-41.5
MCV-92 MCH-31.6 MCHC-34.4 RDW-15.0 Plt Ct-80*
___ 03:45AM BLOOD WBC-3.5* RBC-4.32* Hgb-14.0 Hct-39.7*
MCV-92 MCH-32.3* MCHC-35.2* RDW-14.7 Plt Ct-61*
___ 10:15AM BLOOD WBC-4.3 RBC-4.63 Hgb-15.0 Hct-43.7 MCV-94
MCH-32.5* MCHC-34.4 RDW-15.1 Plt Ct-78*
___ 07:40AM BLOOD WBC-3.8* RBC-4.66 Hgb-14.8 Hct-44.0
MCV-94 MCH-31.8 MCHC-33.6 RDW-15.4 Plt ___
___ 01:55PM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-141
K-6.7* Cl-102 HCO3-18* AnGap-28*
___ 03:45AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-140
K-3.5 Cl-103 HCO3-29 AnGap-12
___ 07:40AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
___ 01:55PM BLOOD ALT-100* AST-216* AlkPhos-86 TotBili-0.5
___ 10:15AM BLOOD ALT-131* AST-139* AlkPhos-61 TotBili-0.5
___ 07:40AM BLOOD ALT-139* AST-86* AlkPhos-57 TotBili-0.3
___ 01:55PM BLOOD Lipase-71*
___ 01:55PM BLOOD Albumin-5.0 Calcium-8.8 Phos-5.7* Mg-2.5
___ 07:40AM BLOOD Calcium-9.4 Phos-5.0* Mg-2.0
___ 03:41AM BLOOD calTIBC-213* Ferritn-288 TRF-164*
___ 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 01:55PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:00AM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. HydrOXYzine 12.5-25 mg PO Q6H:PRN anxiety
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Pantoprazole 40 mg PO Q24H
9. Senna 1 TAB PO BID:PRN constipation
10. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. Alcohol intoxication
2. Alcoholic hepatitis
3. Suicidal ideation
Secondary Diagnosis
1. Depression
2. Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Alcohol withdrawal and presumed towel colic hepatitis, persistent
right upper quadrant abdominal pain despite improving LFTs.
TECHNIQUE: Abdomen ultrasound (complete study).
COMPARISON: None.
FINDINGS:
The hepatic echotexture appears within normal limits. No focal nodules or
masses are identified within the hepatic parenchyma. There is no intra or
extrahepatic biliary ductal dilation. The portal vein is patent with flow in
the appropriate direction. Common hepatic duct measures 2 mm. The
gallbladder is nondistended and contains no stones. The mildly thick-walled
appearance of the gallbladder could relate to partial distention. There is no
evidence of pericholecystic fluid or wall edema. Imaged portion of pancreas
appears within normal limits with portions of the pancreatic tail obscured by
overlying bowel gas. The right kidney measures 11.6 cm. The left kidney
measures 9.1 cm and is located in the pelvis. No stones, masses, or
hydronephrosis identified in either kidney. The spleen measures 11.5 cm.
There is no ascites. Imaged portions of the abdominal aorta and IVC are
normal in caliber.
IMPRESSION:
Essentially normal right upper quadrant ultrasound. A mildly thick-walled
appearance of the gallbladder could relate to underdistention and there are no
findings to suggest cholelithiasis or cholecystitis. No biliary dilation.
Incidental note of a pelvic left kidney.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SI
Diagnosed with POISON BY PROPIONIC ACID DERIV, SUICIDE-ANALGESICS, ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-UNSPEC
temperature: 98.1
heartrate: 117.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | PRINCIPLE REASON FOR ADMISSION
___ yo male w/ history of ETOH abuse, presented with prolonged
ETOH consumption and suicide attempt with ibuprofen ingestion.
# ETOH abuse w/ history of withdrawals. Patient was admitted to
the MICU initially, and was placed on q2h CIWA of 10mg for score
>10. He was also started on clonidine 0.1mg BID. Per psychiatry
recommendations, on ___ he was started on 12mg PO q4h standing
and then started on a taper: day 2: 10mg PO q4, day 3: 8mg PO
q4, day 4: 6mg PO q4, day 5: 4mg PO q4. He was then transferred
to the floor where standing valium taper was continued with prn
valium 10mg q2-4hours for CIWA>10. He continued score heavily on
CIWA for anxiety, but by time of discharge was not scoring for
>24 hours. He was also started on thiamine, folate, and MVI and
social work met with the patient.
# Suicidal ideation: Prior to admission, patient intentionally
overingested ibuprofen in a presumed suicide attempt. On
admission, he was denying and HI and SI. UTox and Serum tox
were remarkable for ETOH only. No other coingestion. He was
monitored with a 1:1 sitter. Hydroxyzine was started for
persistent anxiety. He will be transferred to inpatient psych.
# Abdominal pain: Patient complained of mild RUQ pain on
admission and LFTs were mildly elevated. Appeared consistent
with alcoholic hepatitis. His MDF was 1 and patient did not
require steroids. His LFT's and pain improved. However, he did
develop new lower quadrant abdominal pain in the setting of
constipation for several days. Aggressive bowel regimen was
added and patient received soap suds enema with resultant BM and
improvement in his abdominal pain. Would recommend continued
aggressive bowel reg, rechecking LFT's in one week to ensure
stability, and avoiding acetaminophen.
# Thombocytopenia: likely from alcohol induced bone marrow
suppression.
# Transaminitis: Initially elevated in setting of acute alcohol
ingestion. Initially downtrended. Did have additional bump
during stay after administration of tylenol. Tylenol was DC'd
and LFT's were downtrending on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Right sided chest wall pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo female with a PMH of COPD on home 4L NC,
schizophrenia, HTN, HLD who presents from her group home with
RUQ pain. Her pain began last night , rated as ___, constant,
and worse with movement. She denies worsened pain with
inspiration. She does endorse increased pain with palpation. She
denies fever, chest pain, shortness of breath or cough. Denies
change in pain with eating. She has otherwise been feeling well.
In the ED, her initial VS were 97.2 87 163/64 20 100% on 4 L NC.
Her labs showed WBC 15. RUQ US was normal. CXR showed RLL
infiltrate. She was started on ceftriaxone, azithromycin. VS
prior to transfer were 98.5 74 14 155/85 96% 4L
Currently, she is without complaint and looking forward to
eating lunch.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Glaucoma
HLD
HTN
COPD on 4L home O2
DMII- last A1c 7.2 in ___
Schizophrenia
CKD
dCHF
Morbid Obesity
Vulvar lesion
Osteopenia
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION:
VS - Temp 97.5 F, BP 160/90, HR 90, R 24, O2-sat 94% on 4L NC
GENERAL - obese female in NAD, wearing glasses
HEENT - NC/AT, MMM, OP clear
NECK - supple
HEART - distant heart sounds, RRR, nl S1-S2, no MRG
LUNGS - dimished BS throughout but no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft, obese/ND, TTP in RUQ, neg ___, no
rebound/guarding
EXTREMITIES - redness with 2+ edema to knees, no warmth,
consistent with chronic venous stasis changes.
NEURO - awake, A&Ox3, no focal neuro deficits
DISCHARGE:
VS - 98.7, P: 74, BP: 151/64, RR: 20, 91% on 4L NC
GENERAL - obese female in NAD, wearing glasses
HEENT - NC/AT, MMM, OP clear
NECK - supple
HEART - distant heart sounds, RRR, nl S1-S2, no MRG
LUNGS - dimished BS throughout but no r/rh/wh, resp unlabored,
no accessory muscle use
ABDOMEN - NABS, soft, obese/ND, minimal TTP in over right ribs,
neg ___, no rebound/guarding
EXTREMITIES - redness with 1+ edema to knees, no warmth,
consistent with chronic venous stasis changes.
NEURO - awake, A&Ox3, no focal neuro deficits
Pertinent Results:
Hematology:
___ 06:30AM BLOOD WBC-11.5* RBC-3.59* Hgb-10.7* Hct-33.1*
MCV-92 MCH-29.8 MCHC-32.2 RDW-14.8 Plt ___
___ 10:15AM BLOOD WBC-15.2* RBC-3.89* Hgb-11.2* Hct-36.0
MCV-92 MCH-28.8 MCHC-31.1 RDW-15.0 Plt ___
Chemistries:
___ 06:30AM BLOOD Glucose-67* UreaN-53* Creat-2.2* Na-144
K-3.9 Cl-100 HCO3-33* AnGap-15
___ 10:15AM BLOOD Glucose-219* UreaN-50* Creat-2.1* Na-139
K-4.2 Cl-95* HCO3-31 AnGap-17
___ 10:15AM BLOOD ALT-20 AST-29 AlkPhos-85 TotBili-0.3
___ 06:30AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.3
___ 10:15AM BLOOD HoldBLu-HOLD
FINDINGS: Frontal and lateral views of the chest were obtained.
There is
some increased opacity at the right lung base which could be due
to
atelectasis, although infectious process is not excluded in the
appropriate clinical setting. Left base atelectasis is seen.
There is no pleural effusion or pneumothorax. The cardiac
silhouette is stable but remains mildly enlarged. Mediastinal
and hilar contours are stable.
IMPRESSION: Relative increased opacity at the right lung base
could be due to atelectasis or infection. Stable enlargement of
the cardiac silhouette.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient group home list .
1. ZyprEXA 10 mg PO DAILY
2. Lipitor 80 mg PO DAILY
3. Glargine 85 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: morbid obesity
4. Advair Diskus (250/50) 1 INH IH BID
5. Vitamin D 1000 UNIT PO DAILY
6. Aspirin EC 81 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q4H:PRN pain
8. Furosemide 40 mg PO BID
9. Calcium Carbonate 500 mg PO TID W/MEALS
10. Enalapril Maleate 5 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Calcitriol 0.25 mcg PO EVERY OTHER DAY M, W, F
14. Spiriva HandiHaler 1 CAP IH DAILY
15. Ventolin Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB
16. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
2. Advair Diskus (250/50) 1 INH IH BID
3. Aspirin EC 81 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY M, W, F
6. Calcium Carbonate 500 mg PO TID W/MEALS
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 40 mg PO BID
9. Lipitor 80 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Spiriva HandiHaler 1 CAP IH DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. ZyprEXA 10 mg PO DAILY
14. Glargine 85 Units BedtimeMax Dose Override Reason: morbid
obesity
15. Levofloxacin 750 mg PO Q48H Start: In am
one more dose ___
RX *levofloxacin 750 mg on ___ Disp #*1 Tablet Refills:*0
(Zero)
16. Enalapril Maleate 5 mg PO DAILY
17. Ventolin Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary: Pneumonia; right sided chest wall pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right upper quadrant pain. Evaluate for cholecystitis.
COMPARISONS: None.
FINDINGS: The liver is normal in shape and contour. It has normal
echogenicity. There are no focal hepatic masses. The gallbladder is
nondistended without wall thickening. There is no cholelithiasis or sludge.
The common bile duct is normal and measures 4 mm. There is no intra- or
extra-hepatic biliary duct dilation. There is no ascites.
IMPRESSION: Unremarkable right upper quadrant ultrasound. No evidence of
cholelithiasis or cholecystitis.
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ with right chest and abdominal pain,
pleuritic.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
some increased opacity at the right lung base which could be due to
atelectasis, although infectious process is not excluded in the appropriate
clinical setting. Left base atelectasis is seen. There is no pleural
effusion or pneumothorax. The cardiac silhouette is stable but remains mildly
enlarged. Mediastinal and hilar contours are stable.
IMPRESSION: Relative increased opacity at the right lung base could be due to
atelectasis or infection. Stable enlargement of the cardiac silhouette.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R SIDED PAIN
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.2
heartrate: 87.0
resprate: 20.0
o2sat: 100.0
sbp: 163.0
dbp: 64.0
level of pain: 6
level of acuity: 2.0 | Patient is a ___ yo female with a PMH of COPD on home 4L NC,
schizophrenia, HTN, HLD who presents from her group home with
RUQ pain and found to have RLQ pneumonia as well as WBC of 15
which improved with antiobiotics.
#. Pneumonia: Patient's only symptom of pneumonia was her RUQ
abdominal pain. She denied cough/ SOB. She had no risk factors
for HCAP as she has had no recent hospitalizations. She
initially received ceftriaxone and azithromycin in the ED. She
was started on levofloxacin 750 mg q48h renally dosed on ___
and last dose will be due ___ for a 5 day total course.
#RUQ pain: Consistent with musculoskeletal pain on exam. ___
have been related to RLL pneumonia. Biliary disease
investigated with RUQ US and no evidence of cholelithiasis or
cholecystitis. Her pain was relieved by tylenol. There were no
signs of GI distress- no n/v/d/ bloody or black stools. Her
lipase and LFTs were normal.
#. COPD: stable on home 4 L NC. She was continued on her home
spiriva, albuterol, advair.
#DMII: Last A1c 7.2 in ___. She was continued on her home
insulin regimen.
#CKD: Her creatinine was 2.1 on admission, at baseline. She was
continued on her home calcitriol.
# HTN: Stable. Continued on home lasix, enalapril
#HLD: Stable. Continued on home atorvastatin
#Schizophrenia: Stable. Continued on home zyprexa, sertraline
#CODE: FULL (confirmed with patient) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diarrhea and feeling unwell x 2 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ female s/p allogeneic stem cell
transplantation ___ years ago, c/b chronic GVHD manifesting as
joint aches, increased liver transaminases, and ocular GVH, now
presenting with 2 weeks of diarrhea and feeling unwell. She
describes watery, nonbloody diarrhea for the past 2 weeks along
with difficulty sleeping and decreased oral intake. Her pain is
reproducible and only present when moving. She notes
generalized malaise and right upper quadrant pain as well. She
denies nausea, vomiting chest pain, shortness of breath, fevers,
chills, dysuria while not continued and similar dizziness and
headache.
She was previously admitted on ___, for melena and GI
bleed with drop in hematocrit. Repeat EGD on ___ showed
duodenal
erosions with stigmata of recent bleeding and colonoscopy
showed sigmoid ulceration; neither was felt to be clear source
of
bleed. Capsule study was then performed, not showing a source of
bleeding. She was continued on BID PPI therapy and started on
ampicillin and clarithromycin to complete a 2 week course for
treatment of H. pylori with discharge on ___.
She was then re-admitted on ___ due to increasing lower
back pain radiating to her stomach, and was admitted for further
evaluation. MRI of the thoracic and lumbar spine showed an old
L5 compression fracture and new T11 compression fracture as well
as relatively large right and left paracentral disc herniations
at
T6-T7 and T7-T8, indenting the spinal cord and impinging upon
the exiting nerve roots. This was felt to be explanatory of her
pain. Per Ortho spine, she was given a brace and started on MS
___ 30 BID with continued use of oxycodone, flexeril, and
lidoderm patches and follow up for ?vertebroplasty if
conservative management is not effective. MRCP was performed to
better characterize her abdominal pain which demonstrated
numerous likely side-branch IPMNs (largest was located in head
and 1.8cm in size) for which follow up with
repeat MRCP in 6 months was recommended.
Of note, she has had recurrent DVT's and PE's and has been on
Lovenox. It was discontinued in early ___ as she had
vompleted 6 months of treatment since her last PE and 3 months
since last DVT but she re-presented with leg pain in ___
and lower extremity ultrasound confirmed a nonocclusive thrombus
in a right peroneal vein (?recanalized old thrombus vs. new
thrombus). She was then restarted on Lovenox daily (elevated
levels on BID) which she has continued on, now 40 mg daily.
In the ED, initial vitals were: 98.0 108 120/78 24 96% RA. EKG
showed lateral ST depressions similar to prior with negative
troponins. Labs were notable for baseline LFTs and
electrolytes. CXR unremarkable. Weakly guaiac positive stool.
___ fellow recommended admission for further observation.
On the floor, she explains that she has been having diarrhea
___ and also has some pain over her right side over her
ribs.
Review of Systems:
(+) 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:
- ___: diagnosed with CML, treated with Gleevec.
- ___: admission for myeloblastic crises, treated with 7+3.
Achieved complete molecular and cytogenetic remission
- ___: Myeloablative stem cell transplant with her
matched sister as a donor. Complicated by the development of
acute GVH.
- ___: Admitted on D+147 with GVH that had features of
both acute and chronic (skin rash, mouth ulcers, dry eyes).
- Ongoing issues with chronic GVHD, s/p 2 cycles of
weekly Rituxan for her cGVHD, the last one given in
___. S/p CellCept in ___, stopped due to GI upset.
Current treatment with prednisone
- Admitted on ___ with complaints of left calf pain
after trip to ___ with noted DVT. Chest CTA with acute
pulmonary emboli to the right upper, middle, and lower
pulmonary arteries. Started on Lovenox 80 mg twice per day.
LMWH level high with increasing creatinine so dose
decreased to 80 mg once per day as of ___
- Started Imuran on ___ for treatment of GVHD;
Discontinued on ___ as no changes in GVHD; prednisone
continues.
- Admitted on ___ for evaluation of worsening respiratory
sx's after week on Levaquin with dizziness with the concern
for worsening respiratory process or recurrent PE as she had
missed 3 doses a week earlier. Noted for new DVT in the left
leg but no PE or pneumonia on Chest CTA. CT scan of abdomen
for right flank pain showed no concerning abnormality.
Lovenox dose adjusted to ___aily on discharge.
Discontinued in early ___ as completed 6 month course
since PE and 3 month course since DVT.
- Started Rapamycin 6 mg loading dose x 1 on ___, then
2 mg daily. Prednisone dose decreased to 20 mg daily as
of ___.
- Complaints of abdominal pain and trouble swallowing. EDG
in ___ showed gastric ulcer; started on Prilosec,
continued on Ranitidine. CT scan without abnormalities.
- Admitted on ___ with 1 week of intermittent, several
times per day BRBPR with moderate epigastric and bilateral
lower quadrant pain. No melana. Stools were guaiac
positive. Underwent repeat EGD and colonoscopy which showed
persistent ulcer and several internal anal hemorrhoids.
Restarted Lovenox at 60 mg daily given history of PE's.
- Admitted in ___ for increasing abdominal pain and lower
leg pain. Workup revealed anything acute on chronic rib
fractures which may be contributing to her abdominal pain.
Outpatient arterial examination did not show any claudication.
- ___, started Rituxan for 4 weeks.
- ___, admitted for increasing headaches, abdominal
pain, and leg pain. CT of head did not show any
abnormalities. CT of abdomen and pelvis were without any
abnormalities that explained her pain. MRI of the cervical
spine showed some degenerative changes of the spine and she
was given a cervical collar to wear at night and started on
Flexeril. Seen by ophthalmology and her eye drops have been
switched and they are following her more closely. Also seen
by ___ and started on Insulin.
- Persistent stomach complaints and underwent endoscopy on
___ in follow up of previous ulcers. + gastritis and
+ H pylori.
- ___, Admitted for melana and GI bleed with drop in
hematocrit. Repeat EGD on ___ showed duodenal erosions
with heme spots signifying recent bleeding, colonoscopy showed
sigmoid ulceration, neither felt to be clear source of bleed.
Capsule study done, which also showed no source of bleeding.
Continued on BID PPI therapy and started on ampicillin and
clarithromycin to complete a 2 week course for treatment of
H. pylori. D/ced on ___.
- ___, Admitted for increasing back pain radiating to
abdomen. MRI showed new T11 compression fracture and large
disc herniation at T6-T7 and T7-T8. Given brace and increased
pain medications. Also noted for numerous likely side-branch
IPMNs, largest located in head and 1.8cm in size on MRCP.
PAST MEDICAL/SURGICAL HISTORY:
- Pulmonary embolus in ___ incidentally on CT scan when
admitted for abdominal pain; prior to dx of CML).
- DVT and PE noted on ___ after trip to ___
- New DVT in left leg ___, continued on Lovenox until
___, but restarted in ___ as ? new thrombus in right leg.
- Cholecystectomy ___ years ago
- Sacral insufficiency, fracture in ___
- L5 compression fracture in ___
- T11 compression fracture, ___
- T6-T7 and T7-T8 large disc herniation
- Zometa in ___
- Herpes-Zoster in ___ with admission
- Latent TB (patient received BCG vaccine in ___ per her
report); Had + PPD in ___, was on INH for ~ 1 month in ___
but stopped due to abdominal pain. Restarted on ___ given
continued treatment with immune suppression and possible Enbrel
therapy. Followed by ID. Stopped due to drop in blood counts.
- Left cataract surgery ___.
- EDG on ___ with gastric ulcer, now on Prilosec.
- Repeat EGD in ___ with continued ulcer; repeat in
___ done with other ongoing issues). Colonoscopy with
internal hemorrhoids.
- Repeat EGD on ___, persistent gastritis and + H pylori
Social History:
___
Family History:
Leukemia (+) Brother, ___ Cancer (+) Father.
Physical Exam:
VITALS: T 98.5, BP 106/70, HR 98, RR 18 and 98% RA
General: elderly female in NAD
HEENT: PERRL, EOMI, oropharybx clear
Neck: supple, no LAD
CV: loud IV/VI systolic murmur at RUSB, no rubs/gallops
Lungs: CTAB
Abdomen: soft, mildly tender diffusely, nondistended, no HSM
GU: no Foley
Ext: multiple bruises over extremities without edema, 2+ pulses
Neuro: CN II-XII intact, full strength and sensation throughout,
reflexes not tested
Pertinent Results:
ADMISSION LABS:
==============
141 109 15
----------------122
3.8 20 0.9
Trop-T: <0.01
ALT: 78 AP: 227 Tbili: 0.2 Alb: 3.5
AST: 97 Lip: 31
5.3 \ 27.7 / 128 (MCV 80)
N:80 Band:0 ___ M:8 E:2 Bas:1
CXR (___):
IMPRESSION:
No significant change since the prior study with no new focal
consolidation.
.
MICRO
======
Blood Culture, Routine (Final ___: NO GROWTH.
STOOL: C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
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.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
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.
___ 2:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
OVA + PARASITES (Pending):
.
IMAGING
=========
ECG ___:
Sinus rhythm. Cannot exclude prior anteroseptal myocardial
infarction.
Compared to the previous tracing there is less ST segment
depression/T wave inversion in the inferolateral leads. The
other findings are similar.
TRACING #2
.
CXR ___
FINDINGS: PA and lateral chest radiographs were provided. There
is no large focal consolidation, pleural effusion or
pneumothorax. Overall there is unchanged appearance of the
lungs compared to the most recent prior chest x-ray. The
cardiomediastinal silhouette is stably enlarged. The bones are
intact. The imaged upper abdomen is unremarkable.
IMPRESSION: No significant change since the prior study with no
new focal
consolidation.
.
DISCHARGE LABS:
===============
___ 09:35AM BLOOD WBC-4.6 RBC-3.34* Hgb-8.9* Hct-27.0*
MCV-81* MCH-26.7* MCHC-33.1 RDW-17.8* Plt ___
___ 09:35AM BLOOD Neuts-68 Bands-2 ___ Monos-5 Eos-0
Baso-0 ___ Metas-2* Myelos-2*
___ 09:35AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-2+
Burr-1+ Pencil-1+ Bite-OCCASIONAL
___ 09:35AM BLOOD Glucose-109* UreaN-11 Creat-0.9 Na-140
K-3.6 Cl-106 HCO3-22 AnGap-16
___ 09:35AM BLOOD ALT-89* AST-100* LD(LDH)-333*
AlkPhos-218* TotBili-0.2
___ 09:35AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.0 Mg-2.0
Iron-225*
___ 05:20AM BLOOD Ferritn-55
___ 09:35AM BLOOD rapmycn-15.4*
___ 06:00AM BLOOD GASTRIN-PND
___ 06:10AM BLOOD VASOACTIVE INTESTINAL POLYPEPTIDE-PND
Medications on Admission:
1. Acyclovir 400 mg PO Q12H
2. Cyclobenzaprine 5 mg PO TID:PRN stiffness, pain
3. Enoxaparin Sodium 40 mg SC Q24H
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
5. Fluconazole 200 mg PO Q24H
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Loperamide 2 mg PO DAILY:PRN diarrhea
8. Lorazepam 1 mg PO TID:PRN insomnia, anxiety
9. Omeprazole 20 mg PO BID
10. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
11. Pravastatin 10 mg PO DAILY
12. PredniSONE 20 mg PO DAILY
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
14. Pyridoxine 50 mg PO DAILY
15. Simethicone 40-80 mg PO QID:PRN gas
16. Sirolimus 1.5 mg PO DAILY
Daily dose to be administered at 6am
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Lidocaine 5% Patch 1 PTCH TD DAILY
20. Metoclopramide 10 mg PO BID
21. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
22. Senna 1 TAB PO BID:PRN Constipation
23. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral daily
24. cycloSPORINE *NF* 0.05 % ___ TID severe GVHD
25. Vitamin D 1000 UNIT PO DAILY
26. Bisacodyl 10 mg PO DAILY
27. Morphine SR (MS ___ 30 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Cyclobenzaprine 5 mg PO TID:PRN stiffness, pain
3. cycloSPORINE *NF* 0.05 % ___ TID severe GVHD
4. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
5. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Lorazepam 1 mg PO TID:PRN insomnia, anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*90 Tablet Refills:*0
9. Metoclopramide 10 mg PO BID
10. Morphine SR (MS ___ 30 mg PO Q12H
11. Omeprazole 20 mg PO BID
12. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours Disp #*90
Tablet Refills:*0
13. Pravastatin 20 mg PO DAILY
14. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
15. Prochlorperazine 10 mg PO Q8H:PRN nausea
16. Pyridoxine 50 mg PO DAILY
RX *pyridoxine 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
17. Simethicone 40-80 mg PO QID:PRN gas
18. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral daily
19. NPH 14 Units Breakfast
20. Enoxaparin Sodium 40 mg SC Q 24H
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC Daily Disp #*30 Syringe
Refills:*0
21. Vitamin D 1000 UNIT PO DAILY
22. Outpatient Lab Work
ICD-9: 279.50
Lab: Rapamycin (sirulimus) level
Please draw BEFORE AM dose
Contact: ___ ___, fax ___
23. Loperamide 2 mg PO DAILY:PRN diarrhea
ONLY take this medication if you are having diarrhea because it
can cause constipation.
24. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
25. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
26. Docusate Sodium 100 mg PO BID:PRN constipation
ONLY take this medication if you are constipated because it can
worsen diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Diarrhea
Secondary:
Chronic myeloid Leukemia CML s/p allogeneic stem cell
Moderate chronic extensive graft versus host disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with general malaise. Question pneumonia.
COMPARISON: Chest radiograph from ___ and CT of the
chest from ___.
FINDINGS: PA and lateral chest radiographs were provided. There is no large
focal consolidation, pleural effusion or pneumothorax. Overall there is
unchanged appearance of the lungs compared to the most recent prior chest
x-ray. The cardiomediastinal silhouette is stably enlarged. The bones are
intact. The imaged upper abdomen is unremarkable.
IMPRESSION: No significant change since the prior study with no new focal
consolidation.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: LETHARGY
Diagnosed with OTHER MALAISE AND FATIGUE, DIARRHEA, CHEST PAIN NEC
temperature: 98.0
heartrate: 108.0
resprate: nan
o2sat: nan
sbp: 120.0
dbp: 78.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with myeloblastic CML s/p
allogeneic SCT ___ years ago complicated by chronic GVH of the
eyes, mouth, skin, and liver, admitted with chief complaint of
diarrhea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L foot infection
Major Surgical or Invasive Procedure:
___ L foot debridement
History of Present Illness:
___ with DM and R sided TMA now presents with a new
ulceration to his left hallux to the ___ clinic. Patient
previously called due to concern two days ago. Pt stated his
ulceration started about a week ago when he peeled off
dry dead skin. It has been bleeding since with increased pain.
On, ___, he noticed pus. He squeezed his toe and
was able to get more out. Since, he has been cleaning it with
saline solution and dressing it with betadine soaked gauze
daily.
Pt admits to increased pain/erythema/edema to his left toe. The
pt was instructed and compliant ___ doing daily dressing changes
with betadine soaked gauze, taking Clinda/Cipro, and now
following up ___ clinic. He denies fever, nausea, vomitting,
lethargy, sweats, chills, or diarrhea.
Past Medical History:
DM2 c/b b/l peripheral neuropathy (diagnosed ___ years ago)
HTN
GERD
Social History:
___
Family History:
Father ___ ___ has DM, previous MI, Mother has previous
___, Breast CA, brother and sister, unknown medical health
Physical Exam:
Admission:
PE:
Vitals: 98.2 102 155/89 18 95%
Gen: pleasant, AAOx3, cooperative
LLE-focused exam: Erythematous and edematous L hallux noted with
a distal tip opening probing to bone. There is some darkened
tissue around the opening, no base is observed. Palpable pulses
noted. Skin temperature is warm to warm proximal to distal.
Pertinent Results:
___ 06:45AM BLOOD WBC-7.0 RBC-4.34* Hgb-12.4* Hct-37.5*
MCV-86 MCH-28.5 MCHC-33.0 RDW-14.3 Plt ___
___ 08:40AM BLOOD WBC-7.3 RBC-4.08* Hgb-12.1* Hct-35.1*
MCV-86 MCH-29.6 MCHC-34.4 RDW-14.2 Plt ___
___ 06:56AM BLOOD WBC-5.5 RBC-4.12* Hgb-11.8* Hct-34.6*
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.4 Plt ___
___ 04:00PM BLOOD WBC-9.6 RBC-4.26* Hgb-12.5* Hct-36.4*
MCV-85 MCH-29.4 MCHC-34.4 RDW-14.2 Plt ___
___ 04:00PM BLOOD Neuts-74.0* Lymphs-17.1* Monos-7.1
Eos-1.4 Baso-0.5
___ 06:45AM BLOOD Plt ___
___ 08:40AM BLOOD Plt ___
___ 06:56AM BLOOD Plt ___
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD ___ PTT-31.1 ___
___ 06:45AM BLOOD Glucose-196* UreaN-12 Creat-0.8 Na-133
K-4.5 Cl-94* HCO3-27 AnGap-17
___ 08:40AM BLOOD Glucose-255* UreaN-15 Creat-0.9 Na-131*
K-4.7 Cl-93* HCO3-28 AnGap-15
___ 06:56AM BLOOD Glucose-200* UreaN-16 Creat-0.7 Na-131*
K-4.3 Cl-96 HCO3-24 AnGap-15
___ 04:00PM BLOOD Glucose-164* UreaN-21* Creat-0.9 Na-131*
K-4.6 Cl-95* HCO3-27 AnGap-14
___ 06:45AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0
___ 08:40AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
___ 06:45AM BLOOD Vanco-14.0
___ 06:55AM BLOOD Vanco-13.2
___ 04:10PM BLOOD Lactate-1.6
___ 1:25 pm TISSUE LEFT GREAT TOE DISTAL PHALYAX.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS AND ___
SHORT
CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
Medications - Prescription
GLYBURIDE - glyburide 2.5 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY
DAY
LISINOPRIL-HYDROCHLOROTHIAZIDE - lisinopril 20
mg-hydrochlorothiazide 12.5 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
METFORMIN - metformin ER 750 mg tablet,extended release 24 hr.
TAKE 1 TABLET BY MOUTH EVERY DAY
SIMVASTATIN - simvastatin 10 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. TEST TWICE A DAY
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra
Test strips. for testing twice a day
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth twice a day as needed for constipation
SENNOSIDES [SENNA LAXATIVE] - Senna Laxative 8.6 mg tablet. 1
tablet(s) by mouth take twice a day as needed for constipation
Discharge Medications:
1. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. GlyBURIDE 2.5 mg PO DAILY
5. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth q8hrs Disp #*21
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L foot infection
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: Diabetic male with left great hallux infection. Evaluate for
osteomyelitis.
TECHNIQUE: Frontal, lateral and oblique views of the left foot.
COMPARISON: Bilateral foot radiograph ___.
FINDINGS:
There is no fracture, dislocation or periarticular erosion. Some irregularity
at the base of the fifth metatarsal is noted from healed prior fracture.
Incidental note of a bipartite fibular sesamoid. Soft tissue defect is noted
in the distal left great toe. This soft tissue defect appears to extend down
to the distal tuft and compared to the prior examination though there may be a
suggestion of some minimal osteolysis. Some degree of sclerosis suggests
chronic osteomyelitis. No subcutaneous emphysema is identified.
IMPRESSION:
Soft tissue defect noted in the distal left great toe extending down to the
distal tuft with suggestion of trace osteolysis which is concerning for
osteomyelitis. Some surrounding sclerosis suggests a chronic component as
well.
Radiology Report
EXAMINATION: FOOT AP, LAT AND OBL, LEFT
INDICATION: ___ man with diabetes status-post left hallux distal
phalangectomy for osteomyelitis; post-operative evaluation.
TECHNIQUE: Portable non-stress frontal, lateral, and oblique radiograph views
of the left foot.
COMPARISON: Left foot radiograph dated ___.
FINDINGS:
There has been interval left hallux distal phalangectomy. There is
subcutaneous emphysema and soft tissue swelling distal the first proximal
phalanx consistent with recent surgery. The distal surface of the proximal
phalanx unremarkable and is unchanged from the prior exam. No acute fracture
or dislocation is seen. There is an osteophyte at the distal ___ metatarsal.
There is surface irregularity and sclerosis at the base of the ___ metatarsal
consistent with an old fracture. Incidental ___ DIP joint fusion, bipartite
lateral sesamoid overlying the ___ phalanx, plantar calcaneal enthesophyte,
and vascular calcifications are noted. There is no suspicious lytic or
sclerotic lesion, bony erosion, periostitis, or radio-opaque foreign body.
IMPRESSION:
Expected post-surgical changes.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: GRT TOE INFX
Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS, TOE NOS
temperature: 98.2
heartrate: 102.0
resprate: 18.0
o2sat: 95.0
sbp: 155.0
dbp: 89.0
level of pain: 0
level of acuity: 3.0 | The patient presented to Dr. ___ on ___ with
worsening L hallux. He was sent to the Emergency Room for
evaluation ___. After thorough evaluation, it was deemed
necessary to admit the patient to the podiatric surgery service
for observation and pain control and operative intervention of
his L hallux. Patient was kept NPO with IVF at midnight for a L
foot debridement the following day. Pt was evaluated by
anesthesia and taken to the operating room. There were no
adverse events ___ the operating room; please see the operative
note for details. Afterwards, pt was taken to the PACU ___ stable
condition, then transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled with IV pain medication
that was then transitioned into an entirly oral pain medication
regimen on a PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. Urine output remained
adequate throughout the hospitalization. The patient received
subcutaneous heparin as well as venodyne boots throughout
admission; early and frequent ambulation were strongly
encouraged while remaining weightbearing to heel to his LLE ___ a
surgical shoe.
The patient was subsequently discharged to home on POD#2. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
He will call the office on on the first business day to schedule
a follow-up appointment with Dr. ___. He will be performing
daily dressing dressing changes and taking Clinda q8hrs for 7
days. he was discharged ___ stable condition with a DSD and
surgical shoe ___ place with all questions answered |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with HTN, GERD, DM2 who presents with 2 days
of
abdominal pain. Started ___ after eating almonds in the
epigastrum. Since then, persistent nausea and constant pain now
in the LLQ. Has had several episodes of non-bloody vomiting,
most
recently ___. Tried tums and zantac without relief. No flatus
since ___. Last BM ___. No fevers or chills. Unable to
tolerate any PO since ___. Pain is currently ___ in
severity. She reports her abdomen feels more bloated than usual.
Past Medical History:
Iron deficiency anemia
Social History:
___
Family History:
No history of early CAD, CVA, or colon cancer.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.2 HR: 92 BP: 143/83 Resp: 16 O(2)Sat: 98
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG.
Abd: S/diffusely tender/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood
Physical examination upon discharge: ___
Pertinent Results:
___ 04:55AM BLOOD WBC-8.1 RBC-4.31 Hgb-12.6 Hct-38.5 MCV-89
MCH-29.3 MCHC-32.8 RDW-13.3 Plt ___
___ 05:20PM BLOOD WBC-15.8* RBC-4.64 Hgb-13.8 Hct-42.0
MCV-90 MCH-29.7 MCHC-32.9 RDW-13.6 Plt ___
___ 04:15PM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-UNABLE TO
___ 05:20PM BLOOD Neuts-80.7* Lymphs-10.7* Monos-8.2
Eos-0.3 Baso-0.1
___ 06:45AM BLOOD Neuts-84.4* Lymphs-10.2* Monos-5.2
Eos-0.1 Baso-0.2
___ 04:40AM BLOOD Glucose-143* UreaN-11 Creat-0.8 Na-138
K-4.0 Cl-102 HCO3-26 AnGap-14
___ 04:40AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.3
___ 04:27PM BLOOD Lactate-1.1
___ 12:07PM BLOOD Lactate-1.3
___: cat scan of abdomen and pelvis:
Closed loop small bowel obstruction with two transition points
seen in the anterior mid abdomen with mild bowel wall
hypoenhancement and minimal free fluid seen in the abdomen and
pelvis.
___: chest x-ray:
No evidence of acute cardiopulmonary process. Subsegmental
bibasilar
atelectasis.
Medications on Admission:
HCTZ 25mg QD
Simvastatin 40mg QD
Metformin 500mg (hasn't filled since ___
Sertraline 50mg QD
Iron
Vitamin D
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Hydrochlorothiazide 25 mg PO DAILY
3. Sertraline 50 mg PO DAILY
4. Simvastatin 40 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with epigastric, RUQ, LUQ abd pain,
no BM or flatus x2 daysNO_PO contrast // evidence of SBO
TECHNIQUE: MDCT images were obtained from the lung bases to the lesser
trochanters . IV and oral contrast was administered. Coronal and sagittal
reformations were prepared.
DOSE: DLP: 907 mGy-cm
COMPARISON: None
FINDINGS:
Thorax: The lung bases are clear bilaterally. The visualized heart and
pericardium are normal.
Liver: The liver is normal in size and attenuation. No focal hepatic lesions
are identified. The portal vein is patent. There is no intra or extrahepatic
biliary duct dilatation. There is trace perihepatic ascites.
Gallbladder: The gallbladder is normal-appearing.
Spleen: The spleen is normal in size and enhancement.
Pancreas: The pancreas shows normal enhancement. There is no pancreatic duct
dilatation or peripancreatic fat stranding.
Adrenals: The adrenal glands are unremarkable bilaterally.
Kidneys: The kidneys display symmetric nephrograms with no evidence of
hydronephrosis or mass lesion in either kidney. The ureters are symmetrical
in their course to the bladder.
Bowel: The stomach is distended. The duodenum is fluid filled but not
distended. There are multiple, fluid-filled, dilated loops of small bowel in
the lower mid abdomen (series 2, image 58) proximal to few collapsed small
bowel loops concerning for small bowel obstruction. There appear to be two
transition points in the anterior mid pelvis (series 2, image 55 through 63)
concerning for a closed loop obstruction. There is may be subtle
hypoenhancement of the bowel wall in a loop with fecalized intraluminal
contents (series 2, image 53 through 65), concerning for possible vascular
compromise. There is small free fluid in the abdomen and pelvis. The large
bowel is unremarkable and mostly decompressed.
Vessels: There is no aneurysmal dilatation of the abdominal aorta. The aorta
and its major branches are patent.
Lymph Nodes: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
Pelvis: The bladder is unremarkable. The rectum and sigmoid colon are normal.
There is minimal free fluid seen in the pelvis.
Osseous Structures/ Soft Tissues: There are no suspicious lytic or blastic
lesions seen in the visualized osseous structures.
IMPRESSION:
Closed loop small bowel obstruction with two transition points seen in the
anterior mid abdomen with mild bowel wall hypoenhancement and minimal free
fluid seen in the abdomen and pelvis. (series 2, image 55 through 63)
NOTIFICATION: These findings were communicated to Dr. ___ telephone
at 10:20 on ___ by Dr. ___.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with SBO, pre-op // Pre-op Surg: ___ (Ex
lap)
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
An orogastric tube is noted coursing into the stomach with the side port just
beyond the GE junction. This could be advanced a few centimeters for more
optimal placement. The lung volumes are mildly decreased bilaterally. There is
no evidence of focal consolidation, pleural effusion, pneumothorax, or frank
pulmonary edema. There is subsegmental atelectasis at the lung bases. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are detected.
IMPRESSION:
No evidence of acute cardiopulmonary process. Subsegmental bibasilar
atelectasis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.2
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 143.0
dbp: 83.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the hospital with abdominal pain.
She underwent a cat scan of the abdomen which showed a closed
loop bowel obstruction. The patient was placed on bowel rest
and had placement of a ___ tube for bowel
decompression. After return of bowel function, the ___
tube was removed and the patient was started on clear liquids
and advanced to a regular diet. Her foley catheter was removed
and she voided without difficulty. She was ambulatory and
passing flatus. Her abdomninal pain had decreased in intensity.
The patient was dishcharged home on HD #5 in stable condition.
An appointment for follow-up was made with her primary care
provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Macrobid /
Lodine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Ultrasound Aspiration of Abdominal Collection
History of Present Illness:
Patient is a ___ female status post recent gastric
sleeve complicated by intra-abdominal abscess and pulmonary
embolus, who presented for evaluation of anterior abdominal
pain. The patient stated that she had a mild cough over the
past few weeks, and feels as though she may have strained her
anterior abdominal wall. Given her history of recent abdominal
complications, she was very concerned that this may represent a
new intra-abdominal or worsening abscess. The patient denies
fever or chills. She noted anorexia, but no nausea at the time.
She stated she felt actually fairly constitutionally well but
weak. Pain today is different from that which she experienced
during her diagnosis of intra-abdominal abscess. Bowels have
been functioning normally, No fever/ chills
Past Medical History:
PMH:
- CAD
- HTN
- Arthritis
- Basal cell CA on scalp s/p excision
- T2DM (resolved after wt loss)
- distant h/o nephrolithiasis
PSH:
- Laparoscopic sleeve gastrectomy on ___
- Laparoscopic gastric band placement in ___
- Laparoscopic gastric band removal on ___
- Cardiac catheterization in ___
- Scalp basal cell cancer s/p excision ___ years ago
- Dx LSC x ~4 for pelvic pain
- D+C x 2
- Cystoscopy
Social History:
___
Family History:
Mother died of heart attack at age ___. Father died of lung
cancer at ___
Physical Exam:
VS: T 98.4, BP 149/69, HR: 80, RR: 18, O2: 100% RA
General: pleasant, NAD
NEURO: awake, alert and oriented x3,
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush, L nasal packing in
place
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
GI: normoactive bowel sounds, soft, non-tender, non-distended,
no
hepatosplenomegaly
MSK: no joint swelling or erythema
Extremities: warm and well perfused, no edema, 2+ DP pulses
palpable bilaterally
SKIN: no rashes, no jaundice
R PICC - no erythema, no TTP
Pertinent Results:
___ 02:05PM GLUCOSE-103* UREA N-26* CREAT-0.7 SODIUM-143
POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-23 ANION GAP-15
___ 02:05PM ALT(SGPT)-24 AST(SGOT)-40 ALK PHOS-116* TOT
BILI-0.2
___ 02:05PM LIPASE-26
___ 02:05PM ALBUMIN-2.9*
___ 02:05PM WBC-9.7 RBC-3.47* HGB-10.0* HCT-31.7* MCV-91
MCH-28.8 MCHC-31.6 RDW-15.7*
___ 02:05PM NEUTS-69.2 ___ MONOS-6.1 EOS-3.6
BASOS-0.3
___ 02:05PM PLT COUNT-645*
___ 01:59PM LACTATE-1.4
___ 01:50PM URINE HOURS-RANDOM
___ 01:50PM URINE GR HOLD-HOLD
___ 01:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 01:50PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:50PM URINE HYALINE-1*
___ 01:50PM URINE MUCOUS-RARE
Medications on Admission:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat pain
3. Enoxaparin Sodium 120 mg SC Q12H
4. Lorazepam 0.25-0.5 mg IV Q4H:PRN anxiety
5. Miconazole Powder 2% 1 Appl TP BID:PRN rash
6. Paroxetine 20 mg PO DAILY
7. Ranitidine (Liquid) 150 mg PO BID
8. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry nose
Discharge Medications:
1. ALPRAZolam 0.25 mg PO QHS:PRN anxiety/insomnia
2. BuPROPion 50 mg PO BID
please CRUSH. (this is pharmacy substitution for pt's home ER
dose)
3. Enoxaparin Sodium 120 mg SC Q12H
4. Fluconazole 400 mg IV Q24H
RX *fluconazole in NaCl (iso-osm) 400 mg/200 mL 400 mg IV DAILY
Disp #*14 Vial Refills:*0
5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
6. Paroxetine 20 mg PO DAILY
7. Ranitidine 150 mg PO BID
8. ertapenem *NF* 1 gram Injection DAILY Duration: 2 Weeks
RX *ertapenem [Invanz] 1 gram One gram IV Daily Disp #*14 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Abdominal Pain
Infected abdominal collection
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with history of intra-abdominal abscesses, now
with productive cough. Evaluate for evidence of pneumonia.
COMPARISONS: PA and lateral chest radiograph on ___ and portable
chest radiograph on ___.
TECHNIQUE: AP upright and lateral chest radiograph.
FINDINGS: The lungs are well inflated. Subsegmental atelectasis in the right
lung base is noted. There is also a small nodule in the right mid lung that
was also present in prior study. No other focal opacities are noted.
Cardiomediastinal and hilar contours are unremarkable. There is a right-sided
PICC that ends in the lower SVC. There is no pleural effusion or
pneumothorax.
IMPRESSION: No radiographic evidence of pneumonia.
Radiology Report
INDICATION: ___ woman with history of gastric sleeve surgery with
recent abscesses, now with abdominal pain.
COMPARISON: CTs ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness with oral contrast only.
Intravenous contrast was not administered due to patient's history of prior
contrast reaction, although the patient states it was remote. Coronal and
sagittal reformats were displayed with 5-mm slice thickness.
CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar
atelectasis. There is no pleural or pericardial effusion.
Evaluation of the intra-abdominal organs is limited without intravenous
contrast. The liver is diffusely hypodense, compatible with fatty deposition.
A region of hypodensity in the spleen (2:14) was better assessed on the prior
contrast enhanced study and may be related to splenic injury or infarct,
unchanged. The gallbladder, pancreas, and bilateral adrenal glands are normal.
There is no hydronephrosis, renal stone or contour-altering renal mass.
Numerous diverticula are seen in the large bowel without inflammatory changes
to suggest diverticulitis. There is no bowel obstruction. A small hiatal
hernia is unchanged.
The patient is status post sleeve gastrectomy. A 2.9 x 3.6 cm fluid
collection adjacent to the diaphragm and the surgical site (2:14) was
previously 3.3 x 4.5 cm, slightly smaller. A second fluid collection along
the surgical site (___), previously had a catheter within it and now has
increased fluid, measuring up to 3.7 x 3.6 cm, including adjacent stranding
and a small focus of extraluminal air (2:29). A third collection in the
anterior mesentery at a site of previous inflammation measures approximately
5.0 x 7.2 cm including adjacent stranding with increased fluid suggesting
organizing collection. Superinfection of these collections cannot be excluded.
Atherosclerotic calcifications are seen in the normal caliber aorta. No
pathologically enlarged mesenteric or retroperitoneal lymph nodes are
identified. Small fat containing umbilical hernia is noted.
CT PELVIS: The rectum is normal. Numerous diverticula are seen in the
sigmoid colon without inflammatory changes. The bladder and uterus are
normal. A 1.9 x 2.8 cm fluid collection in the right hemipelvis (2:63) was
previously 3.5 x 5.9 cm, now smaller. There is no pelvic or inguinal
lymphadenopathy. A fat-containing ventral hernia is again seen. Small
nodules and foci of air in the anterior subcutaneous fat are likely related to
injection.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
IMPRESSION:
1. Multiple abdominal and pelvic fluid collections, two of which are smaller
and two of which are more organized than on ___. Superinfection of these
collections cannot be excluded on this study.
2. Diverticulosis without diverticulitis.
3. Fatty liver.
4. Stable small hiatal hernia.
5. Unchanged splenic hypodense area suggests prior infarct or injury.
Findings discussed with Dr. ___ (surgery) at 5:30pm ___.
Radiology Report
HISTORY: ___ female with abdominal fluid collection. Can this fluid
collection be drained.
COMPARISON: Abdomen CT ___.
FINDINGS: Transverse and sagittal images were obtained of the superficial
tissues in the abdominal midline. A small hypoechoic region is identified
measuring about 2.2 x 2.2 x 4.1 cm. The sonographic appearance is not
consistent with fluid. This area appears to represent solid tissue perhaps
representing scar tissue. No fluid collection is identified.
IMPRESSION: No fluid collection identified in the abdominal midline. Only
solid tissue is visualized.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.4
heartrate: 89.0
resprate: 20.0
o2sat: 99.0
sbp: 146.0
dbp: 68.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ was admitted on ___ for abdominal pain noted at an
outpatient visit. A CT scan of the abdomen was obtained which
revealed multiple abdominal and pelvic fluid collections, two of
which are smaller and two of which are more organized than on
___. She was admitted to the hospital to evaluate for an
abdominal abscess given her recent history.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with
ENT: The patient was admitted with a nasal rocket in place from
a previous nosebleed. ENT was consulted and they made
recommendations for surgery to remove the nasal rocket. It was
removed and there were no further nosebleeds.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. A left lower
lobe pulmonary artery embolism was noted incidentally on CT scan
on a previous admission and therapeutic anticoagulation was
continued. She was continued on her home regimen of Lovenox
___ Q12h at discharge.
GI/GU/FEN: The patient was kept on TPN for nutrition support.
She was started on a stage V diet after ___ made the evaluation
that they were unable to drain any collection.
ID: The patient arrived with recent history of abdominal
abscess. She was afebrile and had a normal white count her
entire stay. She was switched to equivalent formulary
antibiotics during her stay and restarted on Ertapenem and
fluconazole on her discharge. The fluid collection was not
amenable to ___ drainage and on HD3 she was transferred to US for
aspiration. Nothing was aspirated and so she was continued on
her IV antibiotics and plans were made for follow up with ID as
an outpatient with a CT scan in two weeks.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. (See PULM above for
anticoagulation details)
Prophylaxis: The patient continued on therapeutic
anticoagulation
after a LLL PE was discovered on CT on her previous admission.
She was encouraged to ambulate and get OOB to chair as
tolerated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 5
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Bilious Vomiting, abdominal pain, decreased ostomy output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of Chron's disease s/p multiple abdominal operations
with recurrent bowel obstructions managed conservatively
presents
today with 2 days of worsening abdominal pain, nausea, vomiting,
and decreased ostomy output. He denies fever/chills. He has been
having multiple episodes of bilious emesis. No recent illness.
He
was recently admitted in ___ for bowel obstruction managed
conservatively and per patient this feels like his usual
obstructive symptoms.
Past Medical History:
PMH: Crohns disease, chronic bronchitis, asthma, hyperlipidemia,
anxiety
PSH:
-___ proctocolectomy, end ileostomy
-___ takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass, Segmental
enterectomy X2
-___ Exploratory laparotomy, control of multiple small
bleeding points.
Social History:
___
Family History:
No family history of IBD. Father with lung cancer.
Physical Exam:
On Admission:
Vitals: 97.2 126 ___ 97%
Gen: Alert, NAD
CV: RRR
Pulm: CTAB
Abd: Soft, mild distension, mild tenderness to palpation in
the RLQ. The midline incision is well healed. No overlying skin
changes. Ostomy in the LLQ with liquid stool, no significant
gas.
Ext: no c/c/e
On discharge:
Vitals: 99 98.8 77 110/60 96 RA
Gen: NAD, Alert
CV: RRR, Normal S1, S2
Pulm: CTAB
Abd: Large right hernia, reducible. Nontender. Soft,
nondistended. Ostomy in LLQ with pasty stool output and gas
production.
Extr: No c/c/e
Pertinent Results:
___ 11:46PM GLUCOSE-111* UREA N-36* CREAT-2.4*#
SODIUM-135 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
___ 11:46PM CALCIUM-9.3 PHOSPHATE-4.8* MAGNESIUM-1.9
___ 11:46PM WBC-11.4* RBC-5.51 HGB-16.2# HCT-47.2 MCV-86
MCH-29.4 MCHC-34.4 RDW-14.9
___ 11:46PM PLT COUNT-303
___ 09:42PM LACTATE-1.3
___ 12:17PM LACTATE-5.2*
___ 12:00PM GLUCOSE-180* UREA N-39* CREAT-3.8*#
SODIUM-133 POTASSIUM-4.4 CHLORIDE-88* TOTAL CO2-15* ANION
GAP-34*
___ 12:00PM ALT(SGPT)-49* AST(SGOT)-34 ALK PHOS-102 TOT
BILI-1.3
___ 12:00PM LIPASE-120*
___ 12:00PM ALBUMIN-5.6*
___ 12:00PM WBC-18.1*# RBC-6.62*# HGB-19.7*# HCT-56.8*#
MCV-86 MCH-29.7 MCHC-34.7 RDW-15.2
Medications on Admission:
None
Discharge Medications:
1. Loperamide 2 mg PO QID
RX *loperamide [Anti-Diarrhea] 2 mg 1 tab by mouth four times
daily Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Acute Renal insufficieny due tovolume depletion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of small bowel obstruction with abdominal pain and emesis.
COMPARISON: Multiple prior studies with the most recent CT abdomen and pelvis
from ___.
TECHNIQUE: MDCT acquired axial images are obtained through the abdomen and
pelvis after administration of oral contrast only. No IV contrast was
administered. Multiplanar reformatted images were prepared and reviewed
FINDINGS:
CT ABDOMEN WITH ORAL CONTRAST:
Evaluation of visceral organs is limited due to lack of intravenous contrast.
The visualized lung bases are clear. The liver is diffusely hypodense
consistent fatty deposition within the liver. The gallbladder, pancreas,
bilateral adrenal glands, bilateral kidneys, and spleen are within normal
limits. No biliary dilatation is present.
A nasogastric tube tip terminates in the proximal duodenum. Again noted is
focal dilatation of the proximal jejunum measuring up to 5.8 cm, in a similar
appearance as before, with the dilated jejunal loop protruding through the
superior aspect of a large complex ventral hernia, with a sharp transition
point in the caliber of the small bowel at the right edge of this ventral
hernia (2: 47). At this transition point, there is a swirling of small bowel
loops and mesenteric vessels, along with mesenteric edema and prominent lymph
nodes measuring up to 1.2 x 1.1 cm (2:55), as seen previously. Findings again
likely reflect a small bowel obstruction as a result of an internal hernia
through the transverse mesocolon.
The remainder of the small bowel loops remain decompressed, many of which are
contained within a large complex ventral hernia. The patient is status post
proctocolectomy with a left ileostomy. There is no free fluid or free air.
There is no retroperitoneal lymphadnopathy. Abdominal aorta is normal in
caliber.
CT PELVIS WITH ORAL CONTRAST:
Evaluation of visceral organs is limited due to lack of intravenous contrast.
The patient is status post colectomy. A Foley catheter is noted in the
bladder with air distending the bladder, likely post-procedural. The prostate
is unremarkable. There is no free fluid or free air. There is no pelvic or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy.
IMPRESSION:
1. Small-bowel obstruction involving the proximal jejunum in a similar
appearance as before with the dilated jejunal loop protruding through the
superior aspect of a large complex ventral hernia and transition point noted
at the right superior edge of the ventral hernia, likely due to an internal
hernia through the transverse mesocolon with swirling of the mesenteric
vessels and small bowel loops at the point of obstruction. Mesenteric edema
and prominent lymph nodes at the transition point are also similar compared to
the prior exam.
2. Large complex ventral hernia containing multiple loops of decompressed
small bowel.
3. Hepatic steatosis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GENERAL WEAKNESS
Diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.2
heartrate: 126.0
resprate: 16.0
o2sat: 97.0
sbp: 109.0
dbp: 91.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was admitted to ___ Surgery for 2 days of
worsening abdominal pain, nausea, and bilious vomiting. CT scan
in the ED showed small bowel obstruction involving proximal
jejunum with dilated jejunal loop through ventral hernia.
Patient was admitted to ___ 3 surgery for conservative
management of SBO. He arrived on the floor NPO, IV fluids, NG
tube, and foley for urinary output monitoring. Patient's
creatinine in the ED was 3.8 consistent with renal insufficiency
for which he was given fluid rehydration. Additionally he had a
lactate of 5.2 and wbc of 18.1 at time of admission.
Hospital day 2: patient had flatus and stool in his ostomy bag.
Pain was better controlled and he was ambulating with no
difficulties. He was advanced to sips. He remained afebrile with
wbc of 11.4, renal function improved with Cr value of 2.4, and
lactate was at 1.3
Hospital day 3: Patient self removed his NG tube overnight. He
was doing well with sips. His ostomy bag was full of flatus and
he felt better.
Hospital day 4: Patient was advanced to fulls and IV fluids were
discontinued as he was toleating the diet. In the afternoon
patient began experiencing nausea and emesis. An NG tube was
reinserted which produced 2 L of bilious fluids upon insertion.
Ostomy bag was producing minimal flatus. Patient was
transitioned back to NPO, IV fluids, and IV medications. Foley
was removed and patient had no difficulties voiding afterwards.
Hospital day 5: Patient remained NPO,IVF, with NG tube.
Creatinine rose to 1.6 from 1.2 the day prior with a decrease in
urinary output for which patient received IV fluid boluses.
Urinary output responded appropriately to the boluses.
Hospital day ___: NGT with decreased output. Patient's ostomy
showed increased flatus and stool output. NGT was removed after
a successful clamp trial. Patient was out of bed. Improved
urinary output with creatinine of 1.3. Patient was started on
clears with continuing IV fluids given high ostomy output.
Hospital day ___: Patient started on regular diet which he
tolerated well. Patient was maintaining adequate urinary output
with creatinine of 1.3 and IV fluids were discontinued. Patient
had chronic contact dermatitis surrounding ostomy site for which
ostomy nurse evaluated the patient and left appropriate supplied
by bedside.
Hospital day ___: Patient was started on loperamide 2 mg TID
for increased ostomy output which decreased his ostomy
output,although it still remained high. Patient's loperamide was
increased to 2mg QID.Patient was taught to titrate his ostomy
output to 1.5L/day. He was also told to measure the output
daily. He was tolerating regular diet, producing good urinary
output, and ambulating. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
nuts / sea urchin / shellfish derived / apple
Attending: ___.
Chief Complaint:
Neck pain and RUE weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH metastatic lung cancer on nivolumab/ipilimumab and
radiation therapy presenting with neck pain and RUE weakness and
pain.
He reports that his pain is normally ___ but day before
admission woke u p with neck pain that was worse than baseline.
It worsened throughout the day. He was able top sleep through
the
night, but then awoke on day of admission with RUE weakness and
R
elbow pain with continuation of neck pain. He also complained of
RLE pain and weakness which he has had since recent admission.
He
denies bowel or urinary incontinence. No spinal tenderness. No
changes in vision, fevers, chills, nausea, vomiting, diarrhea,
spasms.
Of note, pt has previously had RLE weakness from his
brain metastasis (resolved) then bilateral ___ weakness related
to
L2 nerve compression (also resolved at time of most recent
clinic
visit ___ following palliative RT to L1-5 ending ___.
Also on Dexamethasone taper (currently Dexamethasone 2mg daily).
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Mr. ___ is a ___ yo Asian male with no significant PMHx, light
smoker, who was admitted to ___ on ___ with AMS, left arm
and leg weakness and numbness as well as gait difficulty of
acute
onset. He was evaluated in the ED and had a CT head done which
revealed a left parietal vasogenic edema with suggestion of an
approximately 3.5 x 3.2 cm rounded mass centrally. A subsequent
brain MRI revealed a heterogeneously enhancing 3.4 x 3.1 x 3.6
cm
left parietal mass with surrounding vasogenic edema and mass
effect. In addition to the presenting symptoms including
confusion, numbness to the L side of his face, left sided
weakness, he reported worsening L neck pain, dizziness, poor PO
intake, and headache. He also reports 10lbs weight loss and
cough
with blood streaks for ___ years.
On ___ he underwent an EBUS and TBNA of a 2.4cm LLL mass
was
performed and sent for cytology. Statioin 7 enlarged lymph node
was also sampled. Cytology was consistent with lung
adenocarcinoma.
On ___ he underwent craniotomy for resection of left
frontal
lobe lesion. The pathology was consistent papillary
adenocarcinoma. Immunohistochemistry reveals Ck7, TTF-1 and
Napkin positivity and CK20 negativity, consistent with a primary
lung tumor.
Completed CK treatment to the neurosurgical bed on ___.
On ___ - Started on clinical trial ___ with Nivolumab
and
Ipilimumab.
___ - C1 D1 - Ipi/Nivo
___ - C2 D1 - Nivo
___ - C3 D1 - Nivo
___ - C4 D1 - Nivolumab/Ipilmumab
PAST MEDICAL HISTORY:
Stage IV NSCLC (Adenocarcinoma) with brain metastases (see
oncologic history)
Social History:
___
Family History:
(per OMR) Uncle with CAD. Father with hypertension. Sister,
mother, and 3 children aged ___, ___ all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 100.4
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, ND. Mild TTP.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
NEURO: Cranial nerves II-XII grossly intact.
Strength is ___ ___ in RLE. Normal otherwise.
Gait not checked given L weakness.
DISCHARGE PHYSICAL EXAM
VS: 97.8 PO 118 / 68 79 18 98 RA
GEN: ___ male, WNWD, NAD
HEENT: large sagittal scar over scalp, sclera anicteric, MMM,
oropharynx clear. PERRL with appropriate accommodation to direct
and consensual light. EOMI without nystagmus.
Cards: RRR, S1+S2, no M/R/G
Pulm: CTAB, no W/R/C
Abd: Soft, NTND, normoactive bowel sounds
Skin: Pustular nodular erythematous rash throughout torso, back,
scalp.
Neuro: AAOx3, CN II-XII fully tested intact, strength in L ___
___. Strength in RUE ___ in deltoid, elbow flexion/extension,
wrist flexion/extension, finger abduction, otherwise ___.
Sensation to light touch intact throughout. 2+ patellar reflex
b/l. Mute plantar reflexes b/l, mute Achilles reflex b/l.
Negative pronator drift
Pertinent Results:
Lab results
=============
___ 09:30AM BLOOD WBC-9.1 RBC-4.45* Hgb-12.9* Hct-39.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-13.7 RDWSD-43.8 Plt ___
___ 09:30AM BLOOD Neuts-76.3* Lymphs-9.9* Monos-6.8 Eos-6.3
Baso-0.3 Im ___ AbsNeut-6.96* AbsLymp-0.90* AbsMono-0.62
AbsEos-0.57* AbsBaso-0.03
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-159* UreaN-13 Creat-0.7 Na-133
K-4.2 Cl-95* HCO3-23 AnGap-19
___ 09:30AM BLOOD Glucose-159* UreaN-13 Creat-0.7 Na-133
K-4.2 Cl-95* HCO3-23 AnGap-19
___ 11:13PM BLOOD ALT-36 AST-15 LD(LDH)-340* AlkPhos-240*
TotBili-0.5
___ 07:12AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.4
___ 11:13PM BLOOD Albumin-3.4*
___ 09:47AM BLOOD Lactate-2.6*
DISCHARGE LABS
==============
___ 07:12AM BLOOD WBC-14.5*# RBC-4.43* Hgb-12.5* Hct-38.2*
MCV-86 MCH-28.2 MCHC-32.7 RDW-13.0 RDWSD-40.6 Plt ___
___ 07:12AM BLOOD Glucose-149* UreaN-12 Creat-0.6 Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
___ 11:40PM BLOOD Lactate-1.6
IMAGING
========
___ Imaging CT HEAD W/O CONTRAST ___.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. The 2 mm left medial frontal enhancing lesion seen on the MRI
from 1 day earlier is not identified on the present noncontrast
CT.
3. Stable CT appearance of post treatment changes in the
anterior left
parietal lobe.
4. Stable CT appearance of the 1 cm sclerotic lesion in the
right parietal
bone compared to ___. A subcentimeter faint lytic
lesion in the more posterior/inferior right parietal bone is
better seen on MRI, and is difficult to compare to the prior CT.
___ Imaging MR HEAD W & W/O CONTRAS ___.
IMPRESSION:
1. No intracranial hemorrhage or acute infarction.
2. A punctate 2 mm focus of enhancement in the medial left
frontal lobe with associated FLAIR hyperintense signal, not seen
on prior examinations raises concern for a new focus of
metastatic disease. This lesion does not appear to be
associated with adjacent vessels on MPRAGE sequence. Close
attention on followup is recommended.
3. Stable postoperative changes related to left parietal
craniotomy and mass resection with slight increase in dural
thickening and enhancement, which is likely postoperative.
4. Stable rim enhancement along the inferior portion of the
resection bed when compared with the postoperative study. Given
that the primary lesion
demonstrating rim enhancement, possibility of residual disease
is not entirely excluded.
5. Stable 5 mm and 9 mm right parietal calvarial lesions, which
are suspicious for osseous metastasis. As previously
recommended, radionuclide bone scan would be helpful to further
evaluate.
RECOMMENDATION(S): Stable 5 mm and 9 mm right parietal
calvarial lesions,
which are suspicious for osseous metastasis. As previously
recommended,
radionuclide bone scan would be helpful to further evaluate.
___ Imaging CTA HEAD AND CTA NECK ___
IMPRESSION:
1. No acute hemorrhage. No CT evidence for an acute major
vascular
territorial infarction. Grossly stable post treatment change in
the left
anterior parietal lobe, within the limits of noncontrast CT.
2. Unremarkable head and neck CTA.
3. Multiple new lytic lesions within the cervical and included
upper thoracic spine compared with the prior CTA dated ___, consistent with metastases, which are better assessed on
the cervical/thoracic/lumbar spine MRI from ___.
4. Mild interim enlargement of a right parietal bone lytic
lesion, consist
with a metastasis.
5. Stable right parietal bone sclerotic lesion.
6. Please refer to recent MRI head and spine reports for
additional details.
7. 0.8 cm left thyroid nodule with questionable
microcalcifications.
RECOMMENDATION(S):
1. MRI would be more sensitive for an acute infarction or
intracranial
metastases. MRI has already been performed at the time of final
interpretation.
2. Consider thyroid ultrasound for further evaluation of the
suspicious left thyroid nodule.
___ Imaging MRI CERVICAL, THORACIC,
IMPRESSION:
1. Diffuse bone metastases as described above, with contact of
thecal sac at L2 without definite nerve root involvement.
2. No spinal cord compression or signal abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID:PRN cough
2. LevETIRAcetam 500 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
4. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
5. FoLIC Acid 1 mg PO DAILY
6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
7. Dexamethasone 4 mg PO BID
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Dexamethasone 2 mg PO DAILY
2. LevETIRAcetam 1000 mg PO BID
3. Benzonatate 100 mg PO BID:PRN cough
4. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE:PRN
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
8. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
___ PARALYSIS
METASTATIC STAGE IV LUNG NSLC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: *** CODE CORD *** History: ___ with history of metastatic lung
cancer with worsening neck pain and now right-sided weakness (RUE, RLE) over
the past 2 days.IV contrast to be given at radiologist discretion as
clinically needed
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 8 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: CT chest ___, CT L-spine ___, MRI total
spine ___
FINDINGS:
Multiple T2/FLAIR hyperintense, enhancing bone lesions are seen, including in
C5, the left lamina of T1, T4, T6, T8, T9, T10, multiple lesions in L1,
multiple lesions in L2, and L4. There is mild associated superior endplate
compression deformity of T9. At L2, there is involvement of the left pedicle,
transverse process, and lamina, with cortical breakthrough and left thecal sac
contact (19:25).
CERVICAL:
Cervical alignment is anatomic. Intervertebral disc signal intensities appear
normal. The spinal cord appears normal in caliber and configuration. There is
no evidence of high-grade spinal canal narrowing.
At C3-4, there is mild posterior disc bulge, mild left uncovertebral
hypertrophy, and left facet arthropathy which causes mild left neural
foraminal narrowing.
At C4-5, there is mild posterior disc bulge and mild left uncovertebral
hypertrophy which causes mild left neural foraminal narrowing.
At C5-6, there is mild posterior disc bulge and moderate left uncovertebral
hypertrophy which causes moderate left neural foraminal narrowing.
At C7-T1, there is mild right intervertebral osteophyte and facet arthropathy
which causes mild right neural foraminal narrowing.
THORACIC:
Thoracic alignment is anatomic. Intervertebral disc signal intensities appear
normal. The spinal cord appears normal in caliber and configuration.There is
no evidence for high-grade spinal canal or neural foraminal narrowing.
The conus terminates at L1.
LUMBAR:
Lumbar alignment is anatomic. Intervertebral disc signal intensities appear
normal.There is no abnormal signal or enhancement of the terminal cord and
cauda equina.
At L2-3, expansile cystic lesion in the left L2 posterior vertebral body
extending to the pedicle and facets results in at least moderate to severe
left neural foraminal narrowing. There is mild spinal canal narrowing
secondary to mild cortical expansion. There is no significant right neural
foraminal narrowing. Is.
At L3-4, there is mild-to-moderate diffuse disc bulge which causes mild
bilateral neural foraminal narrowing.
At L4-5, there is mild-to-moderate diffuse disc bulge with mild bilateral
neural foraminal narrowing.
At L5-S1, there is mild diffuse disc bulge without spinal canal or neural
foraminal narrowing.
OTHER: Medial left lower lobe lung mass was better evaluated on recent CT
chest. A nonenhancing T2 hypointense cystic lesion in the superior left renal
pole measuring approximately 6 mm is similar in size to prior CT examination,
likely representing an hemorrhagic cyst.
IMPRESSION:
1. Diffuse bone metastases as described above, with contact of thecal sac at
L2 without definite nerve root involvement.
2. No spinal cord compression or signal abnormality.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ male with lung cancer with known metastasis,
presenting with right upper and lower extremity weakness. Evaluate for
intracranial cause and vascular patency.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.5 s, 43.0 cm; CTDIvol = 32.2 mGy (Head) DLP =
1,383.7 mGy-cm.
Total DLP (Head) = 2,313 mGy-cm.
COMPARISON: MRI head ___ dating back to ___
CTA head and neck ___ MR head
MRI entire spine ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of intracranial hemorrhage or acute major vascular
territorial infarction. Patient is status post left parietal craniotomy.
Small hypodensity at the left anterior parietal resection site (3:22)
corresponds to post treatment change seen on the ___ MRI, grossly
unchanged allowing for differences in modalities.
Corresponding to the right parietal calvarial lesions that are seen on recent
MRI head is a sclerotic lesion measuring 9 mm (03:24), and a lytic lesion
measuring 5 mm (03:25). The 9 mm sclerotic lesion is unchanged from ___. The 5 mm lytic lesion is new or more conspicuous compared to prior CTA
dated ___.
The visualized paranasal sinuses and bilateral mastoid air cells appear clear.
CTA NECK:
There is a 3 vessel aortic arch. The carotid and vertebral arteries and their
major branches appear patent without stenosis or occlusion. There is no
evidence of dissection. There is no stenosis of the internal carotid arteries
by NASCET criteria.
CTA HEAD:
The vessels of the circle of ___ and the principal intracranial branches
appear patent without flow-limiting stenosis or aneurysm. The dural venous
sinuses appear patent.
OTHER:
The visualized lung apices appear unremarkable. Nonenlarged paratracheal
lymph nodes are seen bilaterally. There is no cervical lymphadenopathy per
size criteria. Bilateral palatine tonsilliths are likely sequela of prior
infections. There is a 9 x 8 mm left thyroid nodule with tiny internal
hyperdensities, which are questionable for microcalcifications (5:82).
When compared with the prior CTA from ___, there are multiple new
lytic lesions within the visualized cervical and upper thoracic spine (5:178,
166, 138, 133, 119, 11, 8). This is assessed in greater detail on the
cervical/thoracic/lumbar spine MRI from ___ appear
IMPRESSION:
1. No acute hemorrhage. No CT evidence for an acute major vascular
territorial infarction. Grossly stable post treatment change in the left
anterior parietal lobe, within the limits of noncontrast CT.
2. Unremarkable head and neck CTA.
3. Multiple new lytic lesions within the cervical and included upper thoracic
spine compared with the prior CTA dated ___, consistent with
metastases, which are better assessed on the cervical/thoracic/lumbar spine
MRI from ___.
4. Mild interim enlargement of a right parietal bone lytic lesion, consist
with a metastasis.
5. Stable right parietal bone sclerotic lesion.
6. Please refer to recent MRI head and spine reports for additional details.
7. 0.8 cm left thyroid nodule with questionable microcalcifications.
RECOMMENDATION(S):
1. MRI would be more sensitive for an acute infarction or intracranial
metastases. MRI has already been performed at the time of final
interpretation.
2. Consider thyroid ultrasound for further evaluation of the suspicious left
thyroid nodule.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ male with metastatic lung cancer status post left
parietal craniotomy and mass resection with left arm weakness. Evaluate for
stroke.
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: ___ MR head
FINDINGS:
There are stable postsurgical changes related to left parietal craniotomy and
mass resection, with unchanged appearance of a cystic cavity with rim of
chronic blood products. There is slight increase in dural thickening and
enhancement. There is stable rim enhancement along the inferior aspect of the
resection cavity, which is unchanged from ___ (1000: 106).
A new 1-2 mm punctate focus of enhancement in the medial left frontal lobe
with associated FLAIR hyperintensity (series 1000, image 86; series 7, image
12) is visualize, concerning for new focus of metastatic disease.
Otherwise, there is no evidence of new hemorrhage, acute infarction, edema, or
midline shift. The ventricles are normal in size. There is a stable 5 mm T1
hypointense lesion within the right parietal calvarium (3:10, 502:23) with an
additional adjacent 9 mm T1 hypointense right parietal calvaria lesion
(09:18).
There is mild mucosal opacification of bilateral ethmoid air cells. The
remaining paranasal sinuses appear clear. There is increased mucosal
opacification of the left mastoid air cells. The right mastoid air cells
appears clear.
IMPRESSION:
1. No intracranial hemorrhage or acute infarction.
2. A punctate 2 mm focus of enhancement in the medial left frontal lobe with
associated FLAIR hyperintense signal, not seen on prior examinations raises
concern for a new focus of metastatic disease. This lesion does not appear to
be associated with adjacent vessels on MPRAGE sequence. Close attention on
followup is recommended.
3. Stable postoperative changes related to left parietal craniotomy and mass
resection with slight increase in dural thickening and enhancement, which is
likely postoperative.
4. Stable rim enhancement along the inferior portion of the resection bed when
compared with the postoperative study. Given that the primary lesion
demonstrating rim enhancement, possibility of residual disease is not entirely
excluded.
5. Stable 5 mm and 9 mm right parietal calvarial lesions, which are suspicious
for osseous metastasis. As previously recommended, radionuclide bone scan
would be helpful to further evaluate.
RECOMMENDATION(S): Stable 5 mm and 9 mm right parietal calvarial lesions,
which are suspicious for osseous metastasis. As previously recommended,
radionuclide bone scan would be helpful to further evaluate.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with non-small cell lung cancer and brain
metastases who presented with a hemorrhagic stroke. Any change in hemorrhagic
area?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: CTA head and neck dated ___.
MR head with and without contrast dated ___.
Head CT from ___.
FINDINGS:
There is no evidence of acute hemorrhage or mass effect. The patient is
status post left parietal craniotomy with unchanged small hypodensity in the
left anterior parietal surgical bed. The 2 mm left medial frontal enhancing
lesion seen on the MRI from 1 day earlier is not identified on the present
noncontrast CT. There is no sulcal effacement or shift of midline structures.
Ventricles and sulci are age-appropriate.
1 cm sclerotic lesion in the right parietal bone, image 4:28, is unchanged
compared to ___. A subcentimeter faint lytic lesion in the more
posterior/inferior right parietal bone, better seen on MRI, is difficult to
compare to the prior CT, image 4:26.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Dysconjugate gaze is noted.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. The 2 mm left medial frontal enhancing lesion seen on the MRI from 1 day
earlier is not identified on the present noncontrast CT.
3. Stable CT appearance of post treatment changes in the anterior left
parietal lobe.
4. Stable CT appearance of the 1 cm sclerotic lesion in the right parietal
bone compared to ___. A subcentimeter faint lytic lesion in the
more posterior/inferior right parietal bone is better seen on MRI, and is
difficult to compare to the prior CT.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Body aches, Dyspnea, Chest pain
Diagnosed with Cervicalgia, Weakness
temperature: 98.1
heartrate: 85.0
resprate: 19.0
o2sat: 100.0
sbp: 104.0
dbp: 63.0
level of pain: 10
level of acuity: 2.0 | ___ ___ speaking man with a history of metastatic lung AC
presenting with back pain with acute R sided weakness
BRIEF HOSPTIAL COURSE
# METASTATIC STAGE IV LUNG NON SMALL CELL LUNG CANCER, |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___,pcn
Attending: ___.
Chief Complaint:
Head strike with supratherapuetic INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx afib, recent small stroke w/ minimal residual
deficit who was recently started on coumadin post stroke,
transferred from ___ after falling at home with head strike
and supratherapeutic INR. A head CT was negative at ___ but
due to lack of neurosurgical services, the patient was
transferred here.
The pt fell about 24 hours ago after getting up to urinate at
night. She denies symptoms prior to fall such as dizziness,
lightheadedness, vasovagal syptoms, and had no LOC. She fell
from standing as she reports tripping due to the thick carpeting
in her home, and hitting her right face on carpeted floor. She
reports difficulty with her walker as it sticks to the carpet.
After falling, she felt fine and reports getting up and going
back to bed before being found the subsequent morning by her ___
with a bruise over her right face at which point she presnted to
___.
The patient actually reports returning from hospitalization and
rehab just a few weeks ago after a "series of small strokes," at
which point she was started on warfarin. Up until the event
yesterday, she reports doing very well.
In the ED intial vitals were Pain 0, T 98.7, HR 53, BP 187/70 RR
13 O2 97% RA. Pt was admitted for observation. Notably, INR was
3.9.
On the floor, patient is comfortable and has no complaints.
Review of Systems:
(+)
(-) 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:
Afib
Anemia
Arthritis
HLD
Colostomy
CVA
Hypothyroidism
Celiac Disease
Social History:
___
Family History:
Mom- DM
Brother- CAD
Negative for cancer or CVA
Physical Exam:
ADMISSION EXAM:
Vitals- 98.4 BP 182/66 51 18 99% RA
General- Alert, oriented, no acute distress
HEENT- Bruise over left forehead/eye, PERRL, EOMI, 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, Harsh systolic
murmur heard throughout precordium with minimal radiation to
carotids.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, notable for
presence of ostomy bag
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, ___ strength and sensation in tact of
upper and lower extremities
DISCHARGE EXAM:
Vitals- 98.2, 144/67, 54, 16, 100% RA
General- Pleasant, sitting up in chair reading, NAD
HEENT- Normocephalic. Bruising around right eye from fall.
Sclera anicteric, PERRL, EOMI, MMM, oropharynx clear.
Neck- supple, JVP not elevated, no carotid bruits
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Bradycardic with regular rhythm, normal S1 + S2, ___ harsh
systolic murmur heard best at LUSB and can be heard throughout
the precordium. NO rubs or gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Colostomy
bag in LLQ with both air and stool in the bag. Stool is brown in
color with no e/o frank blood
Neuro- A+O x 3
Pertinent Results:
ADMISSION LABS:
___ 08:26PM BLOOD WBC-6.0 RBC-3.44* Hgb-9.6* Hct-29.0*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.4 Plt ___
___ 08:26PM BLOOD Neuts-61.4 ___ Monos-5.8 Eos-2.7
Baso-0.6
___ 08:26PM BLOOD ___ PTT-39.4* ___
___ 08:26PM BLOOD Glucose-92 UreaN-26* Creat-1.1 Na-138
K-4.6 Cl-103 HCO3-29 AnGap-11
___ 08:26PM BLOOD Iron-41
___ 08:26PM BLOOD calTIBC-280 Ferritn-63 TRF-215
PERTINENT LABS:
___ 05:50AM BLOOD Hgb-9.7* Hct-28.1*
___ 05:15AM BLOOD WBC-6.1 RBC-3.44* Hgb-9.8* Hct-28.9*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.6 Plt ___
___ 05:50AM BLOOD ___
___ 05:15AM BLOOD ___ PTT-35.3 ___
___ 05:50AM BLOOD Ret Aut-1.5
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-5.9 RBC-3.25* Hgb-9.2* Hct-27.3*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.7 Plt ___
___ 05:15AM BLOOD ___ PTT-35.1 ___
URINE:
___ 09:17PM URINE Color-Straw Appear-Clear Sp ___
___ 09:17PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 09:17PM URINE RBC-4* WBC-4 Bacteri-FEW Yeast-NONE
Epi-<1
MICRO: None
IMAGING:
___ ECG
Sinus bradycardia. Left anterior fascicular block. Baseline
artifact.
Otherwise, within normal limits. No previous tracing available
for comparison.
___ CAROTID SERIES COMPLETE
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is mild heterogeneous plaque in the
ICA. On the left there is mild heterogeneous plaque seen in the
ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 45/13, 74/20, 69/15,
cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak
systolic velocity is 106 cm/sec. The ICA/CCA ratio is .89.
These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak
systolic
velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec.
The ICA/CCA
ratio is 1.0. These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
IMPRESSION: Right ICA<40% stenosis.
Left ICA<40% stenosis.
___ ECG
Sinus bradycardia. P-R interval prolongation. Left atrial
abnormality. Left axis deviation with left anterior fascicular
block. Compared to the previous tracing of ___ there is no
significant diagnostic change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 300 mg PO Q2D
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Paroxetine 10 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Paroxetine 10 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
6. Amiodarone 100 mg PO DAILY
RX *amiodarone 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES:
Fall
Atrial Fibrillation s/p embolic stroke
SECONDARY DIAGNOSES:
Hypertension
Celiac disease
Dyslipidemia
Hypothyroidism
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
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with history of A/Fib, and recent small stroke,
with a non palpable left carotid pulse.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is mild heterogeneous plaque in the ICA. On the left there is
mild heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 45/13, 74/20, 69/15, cm/sec. CCA peak systolic
velocity is 83 cm/sec. ECA peak systolic velocity is 106 cm/sec. The ICA/CCA
ratio is .89. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 45/9, 67/16, 63/12, cm/sec. CCA peak systolic
velocity 62 cm/sec. ECA peak systolic velocity is 102 cm/sec. The ICA/CCA
ratio is 1.0. These findings are consistent with <40% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA<40% stenosis.
Left ICA<40% stenosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL, HIGH INR
Diagnosed with SYNCOPE AND COLLAPSE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, ABNORMAL COAGULATION PROFILE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.7
heartrate: 53.0
resprate: 18.0
o2sat: 97.0
sbp: 187.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ F with PMH significant for Afib, HTN, recent small strokes
with no residual defects now on warfarin and s/p fall at home
presenting from ___ for further evaluation with
concern for intracranial bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ y/o male with a h/o seizure d/o, alcohol abuse,
"schizoaffective d/o" per CHA notes, h/o psychiatric
hospitalization, transferred here from ___ where he had a
witnessed grand mal seizure. CHA did not have ICU beds, so he
was sent to ___ ED, where he was given phenobarbital and put
on a CIWA scale. Etoh level at CHA was 0.
He became acutely agitated in the ED, and required placement of
restraints. On arrival to the floor, he pulled out his IVs and
ran out to the RN station, yelling "I don't want to be here" and
making expletive laden comments. Code purple called and when
security arrived he went back in bed and covered the sheet over
his head and kept his eyes shut tight when questions were asked
of him.
Past Medical History:
Seizure d/o
Alcohol Abuse
Schizoaffective d/o
Social History:
___
Family History:
Not answering questions
Physical Exam:
DISCHARGE EXAM
Gen: Thin male, disheveled, more interactive and able to
articulate than on arrival but still intermittently hostile
Anterior lung exam CTAB
CV: RRR
Unable to perform rest of exam due to patient positioning and
his unwillingness to answer questions
Skin: small 1.5cm abrasion on forehead, no drainage, bleeding,
erythema
Psych: patient with extreme lability of mood without
provocation; intermittently with outbursts and violence,
attempting to rip things from walls; at times redirectable;
though content normal; no signs hallucination, no signs
self-destructive impulses
Neuro: alert and oriented to person and place, generally,
grossly intact neuro exam throughout, observed ambulating
without deficit
Pertinent Results:
___ 01:34AM BLOOD WBC-8.6 RBC-4.85 Hgb-15.3 Hct-47.0 MCV-97
MCH-31.5 MCHC-32.6 RDW-14.3 RDWSD-51.2* Plt ___
___ 12:12PM BLOOD ___ PTT-23.5* ___
___ 01:34AM BLOOD Glucose-87 UreaN-7 Creat-0.8 Na-142 K-4.4
Cl-107 HCO3-23 AnGap-12
___ 04:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:12PM BLOOD Valproa-<3*
___ 01:37AM BLOOD Lactate-0.8
Lung volumes are well expanded. The lungs are clear. The
cardiomediastinal
silhouette and hilar silhouette are normal. Pleural surfaces are
normal.
IMPRESSION:
No acute cardiopulmonary process.
Head CT
\IMPRESSION:
1. No acute intracranial abnormality.
2. Atrophy, atherosclerosis and microvascular ischemic disease.
Old nasal bone fracture.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. CloNIDine 0.1 mg PO TID
2. Valproic Acid ___ mg PO QHS
3. melatonin 3 mg oral QHS
Discharge Medications:
1. Divalproex (EXTended Release) 1000 mg PO DAILY
2. OLANZapine 10 mg PO BID
3. CloNIDine 0.1 mg PO TID
4. melatonin 3 mg oral QHS
Discharge Disposition:
Home
Discharge Diagnosis:
seizure disorder
schizoaffective disorder
Discharge Condition:
Condition: stable
Mental status: alert, oriented to place; severely impaired short
term memory, with impulsivity, all of which are patient's known
baseline
Ambulatory: no deficit
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with history of EtOH abuse, seizures, complaining of
decreased oxygen saturation while sleeping// Pneumonia?
TECHNIQUE: Single AP view of the chest.
COMPARISON: None
FINDINGS:
Lung volumes are well expanded. The lungs are clear. The cardiomediastinal
silhouette and hilar silhouette are normal. Pleural surfaces are normal.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Alcohol abuse with intoxication, unspecified, Epilepsy, unsp, not intractable, without status epilepticus, Hypokalemia
temperature: 98.5
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 114.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
- given new seizure activity, very important to impress upon
patient the need for antiepileptic; decreased valproate to
1000mg EC daily, as there is less risk of seizure if med is
withdrawn
- continue supportive care of patient living in community,
though may ultimately prove unable to tolerate independent
living; continue to assess
#Seizure: Hx of seizure disorder and a question of etoh
withdrawal seizures, though pt does not appear to be drinking at
present. BCA of 0 at CHA. Valproic acid level of 0; further
history gathering reveals that pt had stopped allowing med
administration so the Rx was DC'd. In ED pt was loaded with
valproic acid as well as phenobarb. CIWA were unremarkable on
floor, no clinical signs of withdrawal. No seizure activity.
Neuro on, rec 1000mg Valproic acid EC on DC.
#Schizoaffective d/o
#outbursts: Patient requiring security in ED and restraints,
then had multiple code purples on the floor. Pt with very labile
mood, going from calm to combative and physically
confrontational without clear provocation. Security sitter was
DC'd after first day on ___ floor and patient quickly had a code
purple, threatening nurses. At times requiring IM olanzapine
10mg and sometimes being easily redirectable with offering of a
drink or snack. Extensive coordation with outpatient team at
___, which is very involved. Contact there was ___,
___. See separate documentation from ___ attending
note ___ and SW ___ for further details on patients
current outpatient situation. On day of DC, safe discharge
planned with ___ team for patient to be seen at home upon ___.
Patient sent in chair car accompanied by clinical psychiatrist
to ensure pt calm through return home.
>30 minutes spent on planning on day of discharge including
talking to outpatient team and multiples trips into room to talk
to patient regarding DC |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Protonix / iron
Attending: ___
Chief Complaint:
Fever, myalgias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH T1DM and ESRD s/p kidney/pancreas transplant (___) on
tacro/MMF/pred, c/b mild-mod pancreas rejection (___) and CMV
viremia (___) who presents with fevers (Tm 102), chills
myalgias, sore throat.
On arrival to ED initial vitals were 100.1 103 117/69 19 100%
RA.
Basic labs, renal ultrasound, and CXR were all obtained. He was
given APAP 1000mg, Ketorolac 15mg, Atovaquone 1500mg, metoprolol
tartrate 25mg, mycophenolate sodium ___ 360mg, omeprazole 20mg,
prednisone 5mg, tacrolimus 3.5mg, 1L NS.
On arrival to the floor he says that he is feeling "ok". He says
that his symptoms started mid-day yesterday with back pain being
the predominant symptom. Around the same time he also developed
a
cough that he says was occasionally productive of yellow sputum.
He also has a mild headache that has been getting better. He
denies any lightheadedness, dizziness, SOB, CP, abdominal pain,
sore throat, nausea, vomiting, diarrhea, constipation, melena,
bloody BMs, dysuria.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- s/p pancreas-kidney transplant (___), previously
complicated by CMV viremia now on valganciclovir
- T1DM (complicated by ESRD, previously on PD prior to his
kidney-pancreas transplant). Complicated by diabetic neuropathy
and gastroparesis.
- HTN
Social History:
___
Family History:
- HTN
Physical Exam:
ADMISSION EXAM
==============
VS: 98.3PO 128 / 73 75 18 98 Ra
GENERAL: NAD, sitting up in bed alert, eating dinner
HEENT: atraumatic, normocephalic, PERRL, MMM, EOMI, sclera
anicteric
NECK: supple, no lymphadenopathy appreciated though slightly
tender to palpation of R anterior cervical lymph node chain
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, ronchi or crackles
ABDOMEN: NABS, soft, NT, ND, no rebound or 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 excoriations or lesions, no
rashes
DISCHARGE EXAM
==============
VITALS: 24 HR Data (last updated ___ @ 722)
Temp: 98.5 (Tm 98.5), BP: 120/72 (108-132/65-83), HR: 79
(77-83), RR: 18, O2 sat: 99% (97-99), O2 delivery: RA
PHYSICAL EXAM
GENERAL: NAD, lying in bed
HEENT: atraumatic, normocephalic, PERRL, MMM, EOMI, sclera
anicteric
NECK: supple, no lymphadenopathy
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, ronchi or crackles
ABDOMEN: Soft, NT, ND, no rebound or 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 excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 11:44PM WBC-11.7* RBC-4.17* HGB-9.3* HCT-33.8*
MCV-81* MCH-22.3* MCHC-27.5* RDW-18.5* RDWSD-52.9*
___ 11:44PM NEUTS-83.8* LYMPHS-7.3* MONOS-8.2 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-9.76* AbsLymp-0.85* AbsMono-0.96*
AbsEos-0.01* AbsBaso-0.02
___ 11:44PM PLT COUNT-309
___ 11:44PM ALBUMIN-4.1 CALCIUM-9.6 PHOSPHATE-2.7
MAGNESIUM-1.6
___ 11:44PM LIPASE-23
___ 11:44PM ALT(SGPT)-9 AST(SGOT)-30 ALK PHOS-46 TOT
BILI-0.6
___ 11:44PM GLUCOSE-99 UREA N-17 CREAT-1.1 SODIUM-137
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-17* ANION GAP-22*
___ 12:02AM LACTATE-2.0
DISCHARGE LABS
===============
___ 04:59AM BLOOD WBC-8.1 RBC-4.20* Hgb-9.5* Hct-33.5*
MCV-80* MCH-22.6* MCHC-28.4* RDW-17.4* RDWSD-50.1* Plt ___
___ 04:59AM BLOOD Glucose-88 UreaN-14 Creat-1.0 Na-140
K-4.2 Cl-103 HCO3-25 AnGap-12
___ 04:59AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7
___ 04:25AM BLOOD CMV VL-NOT DETECT
STUDIES
=======
Renal Transplant US
IMPRESSION:
1. Transplant kidney with normal flow dynamics.
2. Persistent pelviectasis and trace pocket of fluid adjacent to
the transplant, as seen previously.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Atovaquone Suspension 1500 mg PO DAILY
4. OLANZapine 7.5 mg PO QHS
5. Metoprolol Tartrate 25 mg PO BID
6. Alendronate Sodium 70 mg PO QSUN
7. Mycophenolate Sodium ___ 360 mg PO BID
8. Tacrolimus 3.5 mg PO Q12H
9. Omeprazole 20 mg PO BID
10. Calcium Carbonate 500 mg PO BID
11. Amitriptyline 100 mg PO QHS
Discharge Medications:
1. Senna 17.2 mg PO BID:PRN Constipation - First Line
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Alendronate Sodium 70 mg PO QSUN
4. Amitriptyline 100 mg PO QHS
5. Atovaquone Suspension 1500 mg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. Metoprolol Tartrate 25 mg PO BID
8. Mycophenolate Sodium ___ 360 mg PO BID
9. OLANZapine 7.5 mg PO QHS
10. Omeprazole 20 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. Tacrolimus 3.5 mg PO Q12H
13.Outpatient Lab Work
___.0
Please collect morning tacrolimus trough level on ___
and send results to attn: Dr. ___ at ___ ___
Transplant Clinic ___
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
Fever
Secondary Diagnosis
ESRD s/p kidney/pancreas transplant (___)
Mild to moderate pancreas rejection (___)
CMV viremia (___)
Type 1 Diabetes Mellitus s/p pancreas transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with h/o pancreas and renal tx now with fever,
myalgias, back pain// eval for flow, infxn
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Ultrasound dated ___. CT dated ___
FINDINGS:
The right midline transplant renal morphology is within normal limits.
Specifically, the cortex is of normal thickness and echogenicity, pyramids are
within normal limits, there is no urothelial thickening, and renal sinus fat
is unremarkable. There is persistent pelviectasis. There is a trace amount
of perinephric fluid, similar when compared to prior CT.
The resistive index of intrarenal arteries ranges from 0.65 to 0.70, within
the normal range, previously 0.52- 0.72. The main renal artery shows slightly
turbulent flow, similar to prior, with normal waveform, with prompt systolic
upstroke and continuous antegrade diastolic flow, with peak systolic velocity
of 158 cm/s, previously 118 cm/s. Vascularity throughout the transplant is
within normal limits. The transplant renal vein is patent and shows antegrade
normal waveform.
IMPRESSION:
1. Transplant kidney with normal flow dynamics.
2. Persistent pelviectasis and trace pocket of fluid adjacent to the
transplant, as seen previously.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: Body aches, Cough, Fever
Diagnosed with Fever, unspecified
temperature: 100.1
heartrate: 103.0
resprate: 19.0
o2sat: 100.0
sbp: 117.0
dbp: 69.0
level of pain: 10
level of acuity: 2.0 | SUMMARY
=======
___ PMH T1DM and ESRD s/p kidney/pancreas transplant (___) on
tacro/MMF/pred, c/b mild-mod pancreas rejection (___) and CMV
viremia (___) who presented with fevers (Tm 102), chills,
myalgias, and sore throat.
ACTIVE MEDICAL ISSUES
=====================
# Fevers, malaise: He presented with reported fevers, chills,
myalgias and sore throat. Symptoms were most concerning for
viral infection. Work up for infection was significant for
negative UA, CXR and blood culture no growth to date at the time
of admission. He was flu negative and respiratory viral panel
antigen screen was negative, with culture pending at the time of
discharge. CMV VL was undetectable. He remained afebrile off
antibiotics and was discharge back to his facility in stable
condition.
CHRONIC MEDICAL ISSUES
======================
#ESRD s/p kidney/pancreas transplant (___). There was no
concern for rejection based on his presentation, renal function
at baseline and normal lipase/amylase on admission labs. He was
continued on home immunosuppressive regimen with Tacrolimus
3.5mg BID, MMF 360mg BID and Prednisone 5mg daily and ppx
medications atovaquone, in addition to alendronate, omeprazole
and calcium. He will have repeat tacrolimus trough level checked
in several days and follow up to be arranged by renal transplant
team.
# HTN: Continued home metoprolol
# Depression: Continued home Amitriptyline and Olanzapine
TRANSITIONAL ISSUES
===================
Pending labs
- Respiratory viral culture
- Blood and urine cultures
Immunosuppression
- Tacrolimus dosing on discharge 3.5mg BID
- Tacrolimus level on day of discharge: 4.4
- Repeat tacrolimus level on ___ with results sent to
Dr. ___ at ___ ___ Transplant clinic |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / Anesthetics - Amide Type
Attending: ___.
Chief Complaint:
Obstructing left renal stone (transfer from ___.
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy
History of Present Illness:
___ transferred from ___ with left ureteral stone, left
hydronephrosis and left flank pain for 3 days.
stone. Has had 3 days of L flank pain, poor POs. Tmax 101.9.
CT demonstrates a 10mm x 5 mm in the proximal mid to left ureter
at the level of L4 with mild proximal ureteral dilation and mild
left hydronephrosis.
The patient is currently comfortable, reporting mild left flank
pain. She denies any nausea, vomiting, chest pain. She reports
fevers and chills.
Past Medical History:
Migraines
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: No apparent distress.
HEENT: MMM, sclera anicteric.
Neck: No lymphadenopathy, supple.
Pulmonary: CTAB, no rales or rhonchi.
Cardiovascular: RRR, normal S1/S2.
Abdomen: Soft, mild LLQ tenderness.
Extremities: No CCE.
Neurologic: Alert and oriented x3.
Skin: No rash, skin eruptions or erythema.
Vascular: Palpable bilateral femoral pulses. Palpable bilateral
brachial and radial pulses.
DISCHARGE PHYSICAL EXAM:
___ 0008 Temp: 98.9 PO BP: 128/76 R Lying HR: 90 RR: 18 O2
sat: 94% O2 delivery: Ra
General: Middle-aged woman in no acute distress. Resting in bed.
HEENT: Sclerae anicteric, MMM, oropharynx clear. Vesicular
lesions in cluster with surrounding erythema on mid lower lip.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Sparse L basilar crackles but otherwise clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, +L nephrostomy w/
overlying bandages that are c/d/I. Nephrostomy tube draining
clear pale yellow urine.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema in LEs.
Pertinent Results:
ADMISSION LABS:
___ 07:29PM GLUCOSE-105* UREA N-20 CREAT-1.1 SODIUM-145
POTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-18* ANION GAP-16
___ 07:29PM estGFR-Using this
___ 07:29PM CALCIUM-7.1* PHOSPHATE-1.7* MAGNESIUM-1.1*
___ 07:29PM WBC-4.2 RBC-3.97 HGB-12.0 HCT-36.6 MCV-92
MCH-30.2 MCHC-32.8 RDW-12.6 RDWSD-42.8
___ 07:29PM NEUTS-75* BANDS-17* LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ___ METAS-4* MYELOS-1* AbsNeut-3.86 AbsLymp-0.08*
AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*
___ 07:29PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:29PM PLT SMR-VERY LOW* PLT COUNT-61*
___ 07:29PM ___ PTT-29.7 ___
OTHER PERTINENT LABS:
___ 03:50AM BLOOD WBC-17.7* RBC-3.61* Hgb-10.7* Hct-32.2*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.3 RDWSD-43.7 Plt Ct-48*
___ 03:30PM BLOOD WBC-22.1* RBC-3.59* Hgb-10.6* Hct-32.3*
MCV-90 MCH-29.5 MCHC-32.8 RDW-13.3 RDWSD-44.0 Plt Ct-57*
___ 06:28AM BLOOD WBC-25.0* RBC-3.39* Hgb-10.2* Hct-30.3*
MCV-89 MCH-30.1 MCHC-33.7 RDW-13.6 RDWSD-44.4 Plt Ct-66*
___ 03:15PM BLOOD WBC-27.0* RBC-3.62* Hgb-10.8* Hct-32.3*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.4 RDWSD-44.1 Plt Ct-82*
___ 04:23AM BLOOD WBC-21.3* RBC-3.38* Hgb-9.9* Hct-30.4*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.6 RDWSD-44.9 Plt Ct-86*
___ 04:45AM BLOOD WBC-15.9* RBC-3.48* Hgb-10.2* Hct-31.1*
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.6 RDWSD-44.5 Plt ___
___ 04:55AM BLOOD WBC-15.6* RBC-3.48* Hgb-10.3* Hct-31.4*
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.6 RDWSD-44.8 Plt ___
___ 03:30PM BLOOD Glucose-87 UreaN-12 Creat-0.4 Na-145
K-4.1 Cl-110* HCO3-26 AnGap-9*
___ 06:28AM BLOOD Glucose-97 UreaN-10 Creat-0.4 Na-147
K-3.5 Cl-109* HCO3-26 AnGap-12
___ 04:23AM BLOOD Glucose-117* UreaN-10 Creat-0.4 Na-145
K-3.0* Cl-104 HCO3-30 AnGap-11
___ 04:45AM BLOOD Glucose-107* UreaN-8 Creat-0.3* Na-148*
K-3.4 Cl-105 HCO3-29 AnGap-14
___ 04:55AM BLOOD Glucose-89 UreaN-7 Creat-0.3* Na-143
K-4.1 Cl-102 HCO3-29 AnGap-12
___ 06:28AM BLOOD Calcium-8.2* Phos-1.7* Mg-1.9
___ 04:23AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6
RADIOLOGY:
------------------
___ CXR
IMPRESSION:
1. Interval increase in pulmonary edema.
2. Interval increase in bibasilar opacification, which may
represent
atelectasis, although a superimposed pneumonia or aspiration
cannot be
excluded.
3. Small bilateral pleural effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Celecoxib 100 mg oral Other
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*16 Tablet Refills:*0
4. Simethicone 80 mg PO QID
RX *simethicone 80 mg 1 tablet by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. HELD- Celecoxib 100 mg oral Other This medication was held.
Do not restart Celecoxib until talking with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Sepsis
Bacteremia
Obstructive nephrolithiasis
Nephrostomy
Tension Headache
Discharge Condition:
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with right CVL placement// right IJ placement
Contact name: ___: ___ right IJ placement
IMPRESSION:
No comparison. Lung volumes are low. Moderate cardiomegaly. Mild pulmonary
edema. Right internal jugular vein catheter. The course of the line is
unremarkable, the tip projects over the cavoatrial junction. No
complications, notably no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new O2 requirement. Admitted for sepsis
(resolving) from UTI/nepholithiasis s/p perc nephrostomy. Evaluate for
consolidation concerning for pneumonia and or pulmonary edema.
TECHNIQUE: Frontal views of the chest.
COMPARISON: Chest x-ray ___.
FINDINGS:
Compared to the prior study, opacification at the lung bases has increased,
which may represent atelectasis, although a superimposed pneumonia or
aspiration cannot be excluded. Pulmonary vascular congestion and pulmonary
edema has increased. Mild-to-moderate cardiomegaly is unchanged. Small
bilateral pleural effusions. The right IJ line terminates at the cavoatrial
junction.
IMPRESSION:
1. Interval increase in pulmonary edema.
2. Interval increase in bibasilar opacification, which may represent
atelectasis, although a superimposed pneumonia or aspiration cannot be
excluded.
3. Small bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with infected left ureteral stone// please
place perc nephrostomy
COMPARISON: CT on ___
TECHNIQUE: OPERATORS: Dr. ___ (Interventional Radiology Fellow) and
Dr. ___ performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
Dr. ___ radiologist, personally supervised the trainee during
the key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 10 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: Fentanyl, Versed
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.3 min, 7 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. 8 ___ 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 left 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 pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. 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
in the collecting system. 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:
Appropriately placed 8 ___ left-sided percutaneous nephrostomy.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the right.
RECOMMENDATION(S): Percutaneous nephrostomy catheter most remain attached to
bag drainage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Kidney stone, Transfer
Diagnosed with Urinary tract infection, site not specified
temperature: 99.1
heartrate: 102.0
resprate: 18.0
o2sat: 94.0
sbp: 91.0
dbp: 56.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ woman with history of kidney stone s/p
lithotripsy in ___, stress and urge incontinence s/p fascial
sling in ___, melanoma ___, r. calf) and arthritis who
presented as a transfer from ___ after 3 day history of
fevers, chills, LLQ abdominal pain, and night sweats found to
have L ureter 10x5mm obstructing stone. She was transferred to
___ for urology evaluation of infected kidney stone. On ___
she underwent percutaneous nephrostomy placement by
Interventional Radiology. She was transferred from the Urology
service to the Medicine service on ___ for further
management and antibiotic treatment for this infection.
Active issues during this admission:
# Sepsis ___ UTI, resolved
# E coli Bacteremia
# UTI secondary to obstructing nephrolithiasis s/p percutaneous
nephrostomy tube
Baseline Cr 0.6. UCx at ___ notable for pan-sensitive E.
coli, with associated GNR bacteremia on BCx. S/p L percutaneous
nephrostomy tube on ___ by Interventional Radiology. Had brief
requirement of pressor support while in the ICU, was stabilized
and improved and transferred to medicine. Had a rising
leukocytosis that then resolved gradually. Urine and blood cx
from ___ grew pan-sensitive Proteus mirabilis and E. coli.
She was on antibiotics at ___, was continued on antibiotics
(ceftazidime and vancomycin, vanc was discontinued on ___ on
___ here at ___, was was transitioned to PO
ciproflocaxin on ___. On discharge, the plan is to continue for
a total of 2 weeks of coverage for E coli bacteremia (end date
will be ___. Pain was managed with acetaminophen and
oxycodone.
# hypoxia
For several days after the patient arrived to the medicine
service, she was requiring ___ supplemental oxygen. It was felt
that this was likely from excessive IV fluids causing a degree
of pulmonary edema. She did not have any symptoms of pneumonia.
She was weaned off of oxygen and was on room air on ___.
# Headache
Bilateral, at temples, lasting 5+ days. Only migraine like
feature is some nausea. Otherwise features most c/w tension
headache. Pt has had migraines in the past (including emesis,
photophobia) and feels this is more like a regular headache.
This was treated with various agents including Fiorcet,
acetaminophen, and metoclopramide.
# Thrombocytopenia: Platelets 61 on admission, down from
baseline of >200. No active signs of bleeding with nadir = 48.
4T score 3 indicating low risk of HIT. Increased gradually as
patient was improving clinically.
# Coagulopathy: Elevated INR up to 1.4. Normal baseline. Likely
i/s/o poor PO intake and recent sepsis. Resolved prior to
admission.. She was given PO Vitamin K 5mg x3 days (___). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Cleocin
Attending: ___
Chief Complaint:
left and arm weakness and trembling.
Major Surgical or Invasive Procedure:
___ Right Burr holes x2 for evacuation of subdural
hematoma.
History of Present Illness:
Mr. ___ is a ___ y/o M who presents with 2 days of left and
arm weakness
and trembling. Pt reports syncopal fall around ___ at which
time head CT was negative at ___. After that
hospitalization patient has been doing well until 2 days ago
when he began to feel unsteady standing and walking. He
developed some "trembling" in his left leg. Yesterday he noted
weakness in his left arm with "trembling" of the left arm.
Today
he had worsening gait and so he brought himself to the ED where
Head CT showed large right sided SDH at ___. He was
started on Keppra for sz prophylaxis and transferred to ___
for
definitive treatment. Mild HA. Denies N/V, dizziness, blurred
vision or double vision, numbness or tingling.
Past Medical History:
PMHx: HTN, High Cholesterol, s/p prostate resection for cancer
Medications: Aspirin, Cardizem CD, Centrum Silver,
Glucosamine-Chondroitin, Hydrochlorothiazide, Simvastatin,
Toprol
XL, Vitamin C, Vitamin E, lisinopril
All: Cleocin, Penicillins
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 97.9 BP: 173/71 HR: 76 R: 18 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic
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.
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, 3 to
2mm 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 in Left UE is 4+/5 in all muscle groups
Otherwise strength is full ___ in Left ___, Right UE and Right
___.
Positive Left Drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness Right.
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented x3. PERRL bilaterally, 3-2mm. EOMs intact
with nystagmus noted with lateral gaze. Face symmetric, tongue
midline. Sensation intact throughout face. Speech fluent and
clear. Comprehension intact.
No pronator drift.
Motor examination reveals ___ strength throughout all four
extremities with the exception of gastroc which is 5- on the
right.
Incision: Staples in place. Clean, dry and intact. No edema,
erythema or discharge.
Pertinent Results:
Head CT without Contrast: ___
1. Interval right burr hole and subdural drain placement.
Decrease in
subdural hematoma with decrease in leftward shift of midline
structures from 10 mm to 5 mm. No new areas of hemorrhage.
2. Small left subdural fluid collection along superior parietal
convexity
again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cardizem CD 180 mg oral QD
3. Multivitamins 1 TAB PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Vitamin E 400 UNIT PO DAILY
9. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Vitamin E 400 UNIT PO DAILY
8. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
9. Acetaminophen 650 mg PO Q8H:PRN Pain
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*40
Tablet Refills:*0
12. Cardizem CD 180 mg ORAL QD
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Outpatient Physical Therapy
ICD9 Code: ___.2
Discharge Disposition:
Home
Discharge Diagnosis:
Right Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man status post burr hole drainage on right x2.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast material. Reformatted coronal and
sagittal and thin-section bone algorithm reconstructed images were obtained.
CTDIvol: 61 mGy.
DLP: 1026 mGy-cm.
COMPARISON: Non-enhanced CT scan from ___.
FINDINGS:
There has been interval right burr hole and drain placement with subsequent
decrease in subdural hematoma and mass effect. The leftward shift of midline
structures has decreased from 10 mm to 5 mm with interval re-expansion of the
right lateral ventricle. There is post-procedural pneumocephalus along the
right frontal convexity. A small superior left parietal subdural fluid
collection is again seen (400b:72, 2:24). There are no new areas of
hemorrhage, edema or territorial infraction noted. The basilar cisterns
appear patent, and there is preservation of normal grey-white matter
differentiation. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval right burr hole and subdural drain placement. Decrease in
subdural hematoma with decrease in leftward shift of midline structures from
10 mm to 5 mm. No new areas of hemorrhage.
2. Small left subdural fluid collection along superior parietal convexity
again noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLE WEAKNESS
Diagnosed with SUBDURAL HEMORRHAGE
temperature: 97.9
heartrate: 76.0
resprate: 18.0
o2sat: 96.0
sbp: 173.0
dbp: 71.0
level of pain: 1
level of acuity: 2.0 | Mr. ___ was admited to the intensive care unit for
observation and taken to the operating room on ___ for
evacuation of the subdural hematoma with placement of subdural
drain. The patient tolerated the procedure well and was
extubated in the OR electively and transferred to the ICU for
recovery. The patient had a post operative NCHCT that was
consistent with expected post operative changes. On exam, the
patient was very alert and neurologically intact. The patient's
diet was advanced and a consult for physical therapy was placed.
On ___ patient is doing well. His JP drain was removed and a
staple was placed. Patient was transfered to the floor. He was
re-started on ___ and a urinalysis was sent for retention.
Results were negative.
On ___ he was re-assessed by ___ who recommended Mr. ___ be
discharged to home with a prescription for outpatient physical
therapy. It was determined he would be discharged to home later
today. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / PhosLo
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Tunnelled dialysis line R chest (___)
Right-sided thoracentesis / chest tube placement (___)
History of Present Illness:
___ yo F w/ PMHx CKD stage III-IV (currently, estimated GFR of
6.72) not yet initiated on hemodialysis, diabetes, HTN, dCHF
(EF>55% ___, mild to moderate MR, presenting with
worsening dyspnea on exertion since ___ of last week (___). She was recently admitted in ___ after an acute
diastolic heart failure exacerbation thought to be ___
hypertension requiring lasix gtt for diuresis.
After that admission, Ms. ___ relates that she was feeling well
and could walk up a flight of stairs without difficulty. She
went to clinic on ___, however, with c/o dyspnea on
exertion x 2 days. At that time, she noted compliance with diet
and medications. Her lasix was increased to 80mg PO BID from and
a CXR revealed a substantial increase in a right sided pleural
effusion. She was 116.8 lbs at that visit. Since increasing her
lasix, she reports that she is still making good UOP but that
she has not symptomatically felt much better. She also noticed
bilateral ankle swelling, a poor PO intake. She has been
weighing herself daily with her ___ and sticks to a low salt
diet. She also watches her fluid intake. She normally sleeps
with two pillows at night and never lays down flat. She denies
any fevers, chills, or cough.
In the ED initial vitals were: 96.8 71 169/45 20 93% on
undocumented O2 supplementation.
- Labs were significant for proBNP 9469, BUN/Cr 109/7.5, WBC
11.7, H&H 8.7/___.0.
- Patient was given 80mg IV lasix and labetalol.
Vitals prior to transfer were: 97.6 72 172/67 22 98%RA.
On the floor, the pt states that she is feeling improved after
lasix in the ED but still with shortness of breath.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
DM II, recently started on insulin, w h/o DKA
Stage IV CKD secondary to diabetic nephropathy
Gout
Dyslipidemia
Secondary hyperparathyroidism
Anemia
L Papillary renal cell carcinoma
Social History:
___
Family History:
Mother - breast cancer
Father - unknown
Brother and Sister - ___
Physical ___:
ADMISSION PHYSICAL EXAM:
==================
Vitals - T: 96.5 BP: 164/67 HR: 72 RR: 22 02 sat: 96% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, JVP elevated to mid-neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: decreased breath sounds at the right base otherwise CTA,
no wheeze
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, +pedal edema
bilaterally. No unilateral leg swelling, negative ___ sign
bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==================
GENERAL: NAD, thin appearing female
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: No LAD, no JVD. Has tunneled line on the right side
(placed by ___ on ___, and is bandaged/clean dry intact.
CARDIAC: RRR, S1/S2, ___ holosystolic loudest at the LUSB,
consistent with MR, no gallops, or rubs
LUNG: Decreased breath sounds at the right base, breath sounds
remainstable mid right lung field, no wheeze or left lower base
crackles.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no lower extremity
edema. PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
PERTINENT LABS:
===========
___ 09:30PM BLOOD WBC-11.7* RBC-2.90* Hgb-8.7* Hct-28.0*
MCV-97 MCH-30.0 MCHC-31.0 RDW-15.8* Plt ___
___ 06:23AM BLOOD WBC-13.7* RBC-2.42* Hgb-7.1* Hct-23.3*
MCV-96 MCH-29.2 MCHC-30.3* RDW-16.2* Plt ___
___ 06:50AM BLOOD WBC-14.4* RBC-2.55* Hgb-7.5* Hct-24.8*
MCV-97 MCH-29.4 MCHC-30.2* RDW-16.0* Plt ___
___ 09:30PM BLOOD Glucose-205* UreaN-109* Creat-7.5*#
Na-135 K-4.3 Cl-104 HCO3-15* AnGap-20
___ 06:23AM BLOOD Glucose-65* UreaN-44* Creat-3.6*# Na-138
K-3.6 Cl-99 HCO3-30 AnGap-13
___ 06:50AM BLOOD UreaN-25* Creat-2.9* Na-136 K-4.0 Cl-98
HCO3-28 AnGap-14
___ 09:30PM BLOOD CK(CPK)-65
___ 01:05PM BLOOD ALT-16 AST-13 AlkPhos-122* TotBili-0.1
___ 06:45AM BLOOD LD(LDH)-201
___ 09:30PM BLOOD Calcium-9.3 Phos-4.5 Mg-1.7
___ 06:23AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
INFECTIOUS DISEASE TESTING:
===================
PPD NEGATIVE - read on ___ 09:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 09:30PM BLOOD HCV Ab-NEGATIVE
THYROID:
======
___ 07:10AM BLOOD TSH-0.82
IRON STUDIES:
========
___ 06:35AM BLOOD calTIBC-135* Ferritn-2151* TRF-104*
CARDIAC ENZYMES/LABS:
===============
___ 06:45AM BLOOD CK-MB-6 cTropnT-0.10*
___ 09:30PM BLOOD cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-6 proBNP-9469*
PLEURAL FLUID TESTING:
===============
LIGHTS CRITERIA: If pleural protein/serum protein >0.5, pleural
LDH/serum LDH >0.6 or Pleural LDH ___ LDH upper limit of
normal - ___ be exudative. - In this case:
Pleural protein = 1.7
Pleural LDH = 63
Plasma protein = 5.4
Plasma LDH = 291
IMAGING:
=======
CT CHEST ___:
Moderate bilateral pleural effusions resulting in partial
bilateral lower lobe
passive atelectasis.
Mild likely infectious small airways disease.
Thyroid goiter with substernal extension.
CHEST XRAY ___:
Persistent opacity at the right mid to lower lung status post
chest tube
placement. Recommend CT to further assess. Interval development
of mild
pulmonary edema. Stable trace left effusion. ***NOTE CT SCAN
ABOVE SHOWS NO MALIGNANCY***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acarbose 50 mg PO TID
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.25 mcg PO 5 DAYS/WEEK
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. CloniDINE 0.6 mg PO BID
7. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection
monthly
8. Furosemide 80 mg PO BID
9. HydrALAzine 40 mg PO TID
10. Glargine 7 Units Bedtime
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Labetalol 600 mg PO TID
13. methoxsalen 10 mg oral prn light therapy
14. Ascorbic Acid ___ mg PO BID
15. Aspirin 81 mg PO DAILY
16. Domeboro 1 PKT TP QID
17. Calcium Carbonate 500 mg PO TID W/MEALS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.25 mcg PO 5 DAYS/WEEK
5. Calcium Carbonate 500 mg PO TID W/MEALS
6. Glargine 7 Units Bedtime
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Labetalol 600 mg PO TID
9. Acarbose 50 mg PO TID
10. Ascorbic Acid ___ mg PO BID
11. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
12. darbepoetin alfa in polysorbat 40 mcg/0.4 mL injection
monthly
13. Domeboro 1 PKT TP QID
14. methoxsalen 10 mg oral prn light therapy
15. HydrALAzine 75 mg PO Q8H
RX *hydralazine 25 mg 3 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Congestive Heart Failure
Secondary Diagnosis:
Chronic Kidney Disease
Diabetes Mellitus Type II
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dyspnea // Eval for pulm edema, PNA
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is persistent large right pleural effusion with overlying atelectasis.
Minimal to no left pleural effusion is seen. No pneumothorax is seen. The
cardiac and mediastinal silhouettes are stable. There may be minimal central
pulmonary vascular congestion.
IMPRESSION:
Persistent large right pleural effusion. Minimal to no left pleural effusion.
Radiology Report
INDICATION: ___ year old woman with CKD III-IV, with recently worsening renal
function and right-sided pleural effusion. // Needs tunneled dialysis line
placed on right side. saving left arm for possible fistula.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Sedation was provided by administrating divided doses of 1 mg of
midazolam throughout the total intra-service time of 45 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: Versed, 1% lidocaine.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 5 min, 18 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 right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent internal jugular vein on the
right 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 23 cm tip to cuff hemodialysis catheter 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 internal jugular vein on the right. Final fluoroscopic image showing
hemodialysis catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a right internal jugular approach 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 right pleural effusion s/p thoracentesis.
// rule out pneumothorax
COMPARISON: ___.
FINDINGS:
AP portable upright view of the chest. There is a persistent opacity at the
right mid to lower hemi thorax now with a pigtail drain in place. Given that
the opacity persists, a mass is difficult to exclude and for this reason a CT
is recommended to further assess. Mild pulmonary edema is new from prior exam.
A tiny left effusion persists.
IMPRESSION:
Persistent opacity at the right mid to lower lung status post chest tube
placement. Recommend CT to further assess. Interval development of mild
pulmonary edema. Stable trace left effusion.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with CKD Stage III-IV, on HD, presenting with
unilateral R sided pleural effusion and possible consolidation on CXR
concerning for cancer. Evaluate for malignancy.
TECHNIQUE: Non-contrast chest CT was performed acquiring sequential axial
images from the thoracic inlet through the adrenal glands. Thin section axial,
coronal, sagittal and axial MIP's were also obtained.
DOSE: 272.33 mGy.
COMPARISON: Chest CT dated ___. Correlation also made to recent
chest radiograph dated ___.
FINDINGS:
Thyroid goiter with substernal extension is noted. Nonspecific mildly
enlarged mediastinal lymph nodes measure up to 9 mm in short axis (4, 80 and
83). No supraclavicular or axillary lymphadenopathy is identified.
A tunneled dialysis catheter extends into the inferior right atrium. There is
mild cardiomegaly with multichamber enlargement. Extensive coronary artery
and aortic valve calcifications are present. There is no pericardial effusion.
The main pulmonary artery and thoracic aorta are normal in caliber, however
calcific atherosclerotic disease diffusely involves the thoracic aorta and its
branches.
Evaluation of the lungs demonstrates scattered bilateral branching tubular
___ opacities and punctate nodules in a predominantly biapical
subpleural distribution. No central endobronchial lesion is identified. There
are scattered areas of linear and subsegmental atelectasis bilaterally.
Moderate bilateral pleural effusions result in partial bilateral lower lobe
passive atelectasis.
Images of the upper abdomen are notable only for dense splenic artery
calcifications, and an indeterminate coarse calcification posterior to the
left spleen.
No destructive osseous lesions are identified.
IMPRESSION:
Moderate bilateral pleural effusions resulting in partial bilateral lower lobe
passive atelectasis.
Mild likely infectious small airways disease.
Thyroid goiter with substernal extension.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED
temperature: 96.8
heartrate: 71.0
resprate: 20.0
o2sat: 93.0
sbp: 169.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | ___ yo F w/ PMHx of CKD stage V not on HD, heart failure with
preserved ejection fraction, diabetes and HTN who presents with
worsening DOE, now improving after lasix ,thoracentesis for R
pleural effusion, and hemodialysis.
# Dyspnea on exertion - At admission, was unable to walk up a
flight of stairs ___ severe dyspnea. Labs revealed rising
creatinine and proBNP that is elevated. CXR was remarkable for
worsening right sided pleural effusion. Her d/c weight was 55.4
kg on ___ and on admission to ___ this hospitalization she
was 53.0kg. Discharge weight was 50.4kg.
Given her compliance with her medications, stable weight and
worsening pleural effusion, most likely etiology of her SOB is
her pleural effusion, although given poor urine output from
patient at home on home lasix, there is also a component of CHF.
Further, her metabolic acidosis was likely driving her tachypnea
as well as evidenced by her VBG which showed metabolic acidosis
with respiratory compensation. No indications of PE given
progressive nature and low wells score (1.5), w/risk of PE of
3%.
During this hospitalization, hemodialysis was initiated via
tunneled catheter that was placed on her right side. She
received dialysis x 3, and subjectively the patient felt much
improved after these sessions with clearer mental status, and
decreasing dyspnea on exertion. Her right lung pleural fluid was
drained during hospitalization with interventional pulmonary
team placing a chest tube, and draining >300 cc of fluid before
removal of the tube. As noted in the results section, the
effusion itself was transudative and unilateral with unclear
etiology. Given concern for malignancy due to the unilateral
aspect of the effusion, a CT scan was performed which showed no
evidence of a mass. By ___ the patient was off of nasal
cannula oxygen and able to ambulate without assistance. At
discharge the patient had a tunneled catheter in place for
outpatient hemodialysis, and will need to receive an AV fistula
as an outpatient to continue long term dialysis management.
She was asked to maintain close followup as an outpatient - both
for management of her CKD and for continuing management (if
needed) for her right sided pleural effusion which ___ need to
be re-drained and further evaluated. Ms. ___ was asked to weigh
herself daily as an outpatient and call MD if >3 lb weight gain
as she ___ need adjustments to her medication or hemodialysis
schedule. At the time of discharge, Ms. ___ was able to ambulate
independently with a steady gait, remained off of supplemental
oxygen and reported no further dyspnea on exertion. She also
remained afebrile throughout this hospitalization.
# CKD stage III-IV with exacerbation to Stage V given GFR
calculation of <7 today.
Multiple causes, very longstanding ___ diabetic nephropathy and
hx rcc s/p L nephrectomy. Has had an acute rise in her
creatinine to 7.5 from baseline 3.9-4.7 in ___. Likely
secondary to progression of her underlying CKD. The reason for
her acute rise in creatinine is unclear at this time. Whether
CKD has worsened --> renal failure --> volume overload, or
whether volume overload is leading to poor renal perfusion, and
then the concomitant rise in creatinine. Patient remained
oliguric at discharge, and she was continued on her renal
medications from home along with additional medications
recommended by our nephrology service. See medications section.
As an outpatient, all medications should continue to be renally
dosed, and scans with IV contrast avoided if possible or
scheduled for shortly before her HD sessions.
# Hypertension
Due to CKD, patient chronically hypertensive. She ___ need
further outpatient management of her HTN, but given that she
puts out no urine to 80mg PO lasix, this can be discontinued,
and her clonidine was discontinued as this medication can have
substantial side effects and requires perfect adherence to
reduce rebound.
At home ON:
Amlodipine 10 mg PO DAILY
CloniDINE 0.6 mg PO BID
Furosemide 80 mg PO BID
HydrALAzine 40 mg PO TID
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Labetalol 600 mg PO TID
She was discharged on:
Amlodipine 10
Hydralazine 75mg PO TID
Isosorbide Mononitrate (ER) 30mg PO daily
Labetalol 600mg PO TID
# Diabetes
Blood sugar was stable this hospitalization. We held her
acarbose as an inpatient, but restarted the acarbose and basal
insulin with sliding scale after discharge.
# Thyroid goiter
Patient not on thyroid medications, and has goiter seen on chest
CT. Normal TSH. Will need to follow up as outpatient.
# Anion gap metabolic acidosis - Likely was related to worsening
uremia.
Unlikely to be lactic acidosis given normal lactate levels, DKA
also unlikely given blood glucose reasonably well controlled, no
other sx and she is type II meaning lower risk. The gap
resolved after the start of dialysis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male with a hx of mitral valve prolapse
and mitral regurgitation, HTN, CKD stage III, COPD (FEV1 41%,
FEV1/FVC70%, not on home O2), gastric adenocarcinoma, presents
today with cough and SOB
Patient reports he was in his normal state of health until ~10
days prior to admission. At that time he developed a dry cough
and SOB. This progress and ___ days prior to admission he was
only able to walk ___ yards (normally can walk ___ city blocks)
and noted a runny nose and sore throat. His coughing persisted
to
the point where he felt he was unable to breath and he presented
tp the ED.
He denies cp, fevers, sick contacts, n/v, diarrhea, changes in
meds or inhaler non-adherence, ___ edema, PND. He had mild
improvement in his symptoms with albuterol. He does endorse ~15
lbs unintentional weight loss over the last year. He notes he
has
an appointment with his outpatient pulmonologist this upcoming
___.
ED Course:
Vitals: Afeb, BP 138/83, RR 20, 97% on 4L
Exam: wheezing
Labs: Trop 0.03-->0.02, BNP 3000, Cr 2.1 (b/l 1.8-2), K 5.7
(hemolyzed), CO2 32, UA bland, WBC 11.5/Hgb 13.6, INR 1,
Imaging: CXR with ?left pleural effusion, cannot exclude
consolidation
Consults: none
Interventions: IV methylpred 80mg, CTX 1g/Azithro 500mg, Mg 2g,
Duonebs
A 10 pt review of systems was obtained and is negative except
per
HPI.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
1. Chronic kidney disease
2. Mitral valve prolapse and moderate mitral regurgitation
3. Hypertension
4. COPD
5. Gastric adenocarcinoma s/p resectionp (pT3N1, stage IIB) with
adjuvant chemoradiation (___)
6. Thyroid nodule, indeterminate for malignancy,
hemithyroidectomy recommended, patient declined
7. Status post prostatectomy (___)
Social History:
___
Family History:
father-died at ___ yo, unknown causes
mother-died of MI at ___ yo
siblings-healthy, no significant pmhx
Physical Exam:
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: BS decreased at L base, no wheezing noted
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no ___, no calf tenderness
NEURO: CNII-XII intact, ___ strength in upper and lower ext, nl
gait
SKIN: no rashes or lesions
Pertinent Results:
___ 08:27AM BLOOD WBC-13.0* RBC-3.60* Hgb-11.2* Hct-33.8*
MCV-94 MCH-31.1 MCHC-33.1 RDW-16.3* RDWSD-56.4* Plt ___
___ 07:00AM BLOOD Glucose-143* UreaN-40* Creat-2.3* Na-139
K-5.0 Cl-99 HCO3-25 AnGap-15
___ 12:24PM BLOOD ALT-23 AST-48* AlkPhos-85 TotBili-0.8
___ 04:53PM BLOOD cTropnT-0.02*
CXR
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SOB // ?PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are hyperinflated, suggesting COPD. There is a small
to moderate
left pleural effusion, similar compared to the prior study, with
overlying
atelectasis. Left base consolidation would be difficult to
exclude. No right
pleural effusion or right-sided focal consolidation is seen.
Cardiac and
mediastinal silhouettes are stable.
IMPRESSION:
Redemonstrated small to moderate left pleural effusion with
overlying
atelectasis, underlying left base consolidation be difficult to
exclude.
___, MD electronically signed on ___ ___
2:21 ___
EKG
Sinus rhythm rate 71, PVCs, old anterior infarct
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN cough
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
3. Tiotropium Bromide 2 CAP IH DAILY
4. amLODIPine 5 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Pravastatin 20 mg PO QPM
7. Chlorthalidone 25 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 5 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Pravastatin 20 mg PO QPM
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN cough
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff inhaled q4h prn
Disp #*1 Inhaler Refills:*0
10. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
11. Tiotropium Bromide 2 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 18 mcg
inhaled once a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
LLL chronic pleural effusion
HTN
HLD
Discharge Condition:
Stable
A/Ox3
self ambulatory
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with SOB // ?PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are hyperinflated, suggesting COPD. There is a small to moderate
left pleural effusion, similar compared to the prior study, with overlying
atelectasis. Left base consolidation would be difficult to exclude. No right
pleural effusion or right-sided focal consolidation is seen. Cardiac and
mediastinal silhouettes are stable.
IMPRESSION:
Redemonstrated small to moderate left pleural effusion with overlying
atelectasis, underlying left base consolidation be difficult to exclude.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with Cough
temperature: 97.7
heartrate: 78.0
resprate: 20.0
o2sat: 100.0
sbp: 138.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Patient as admitted to the floor for COPD exacerbation.
Prednisone 40mg, nebs, and azithromycin were started, and
patient was quickly weaned off of oxygen and wheezing improved.
He will finish a 5 day course of azithromycin and prednisone. He
has a pulmonology follow up in 2 days. We will provide him with
Spiriva and albuterol refills. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cymbalta / tramadol / Lyrica
Attending: ___
___ Complaint:
left knee wound dehiscence
Major Surgical or Invasive Procedure:
left knee I&D polyliner exchange, washout ___, ___
History of Present Illness:
___ year old female with PMH depression, anxiety, HTN, recently
s/p L TKA ___, ___ with traumatic wound dehiscence after
ground level mechanical fall s/p L knee I&D, polyliner exchange
___, ___ now presenting to ED ___ with worsening wound
dehiscence.
Past Medical History:
Hypertension, depression and anxiety, COPD with emphysema
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Aquacel dressing/ace wrap with no serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 05:52AM BLOOD WBC-6.4 RBC-2.61* Hgb-7.7* Hct-24.2*
MCV-93 MCH-29.5 MCHC-31.8* RDW-14.6 RDWSD-49.2* Plt ___
___ 05:08AM BLOOD WBC-6.9 RBC-2.73* Hgb-7.9* Hct-25.0*
MCV-92 MCH-28.9 MCHC-31.6* RDW-14.9 RDWSD-49.8* Plt ___
___ 06:51PM BLOOD Hgb-8.7* Hct-27.4*
___ 06:24AM BLOOD Hgb-7.1* Hct-22.9*
___ 04:54AM BLOOD WBC-6.5 RBC-2.94* Hgb-8.5* Hct-27.9*
MCV-95 MCH-28.9 MCHC-30.5* RDW-14.3 RDWSD-49.4* Plt ___
___ 05:54AM BLOOD WBC-6.8 RBC-2.94* Hgb-8.6* Hct-27.8*
MCV-95 MCH-29.3 MCHC-30.9* RDW-14.3 RDWSD-49.3* Plt ___
___ 06:35AM BLOOD WBC-6.9 RBC-3.03* Hgb-8.8* Hct-28.7*
MCV-95 MCH-29.0 MCHC-30.7* RDW-14.3 RDWSD-49.7* Plt ___
___ 05:42AM BLOOD WBC-8.3 RBC-3.30* Hgb-9.7* Hct-31.5*
MCV-96 MCH-29.4 MCHC-30.8* RDW-14.6 RDWSD-51.0* Plt ___
___ 05:27AM BLOOD WBC-41.3* RBC-2.78* Hgb-9.4* Hct-29.5*
MCV-106* MCH-33.8* MCHC-31.9* RDW-18.9* RDWSD-70.9* Plt ___
___ 01:58PM BLOOD WBC-10.5* RBC-2.83* Hgb-8.4* Hct-27.2*
MCV-96 MCH-29.7 MCHC-30.9* RDW-14.5 RDWSD-50.2* Plt ___
___ 06:35AM BLOOD Neuts-63.4 ___ Monos-9.0 Eos-3.6
Baso-0.7 Im ___ AbsNeut-4.37 AbsLymp-1.56 AbsMono-0.62
AbsEos-0.25 AbsBaso-0.05
___ 05:42AM BLOOD Neuts-61.1 ___ Monos-9.2 Eos-3.3
Baso-0.5 Im ___ AbsNeut-5.05 AbsLymp-2.09 AbsMono-0.76
AbsEos-0.27 AbsBaso-0.04
___ 05:27AM BLOOD Neuts-87* Bands-2 Lymphs-7* Monos-2*
Eos-0* ___ Metas-1* Myelos-1* NRBC-0.2* AbsNeut-36.76*
AbsLymp-2.89 AbsMono-0.83* AbsEos-0.00* AbsBaso-0.00*
___ 01:58PM BLOOD Neuts-74.5* Lymphs-13.7* Monos-8.4
Eos-1.9 Baso-0.5 Im ___ AbsNeut-7.83* AbsLymp-1.44
AbsMono-0.88* AbsEos-0.20 AbsBaso-0.05
___ 01:58PM BLOOD ___ PTT-38.3* ___
___ 05:08AM BLOOD Creat-0.7
___ 06:24AM BLOOD Creat-0.8
___ 06:35AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-103 HCO3-27 AnGap-12
___ 05:42AM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-145 K-4.1
Cl-102 HCO3-26 AnGap-17
___ 05:27AM BLOOD Glucose-102* UreaN-24* Creat-0.7 Na-140
K-4.8 Cl-106 HCO3-22 AnGap-12
___ 01:58PM BLOOD Glucose-89 UreaN-10 Creat-0.8 Na-141
K-3.8 Cl-101 HCO3-24 AnGap-16
___ 05:27AM BLOOD ALT-18 AST-23 AlkPhos-182* TotBili-0.4
___ 06:35AM BLOOD Calcium-9.3 Phos-4.8* Mg-1.8
___ 05:27AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.0
___ 01:58PM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9
___ 05:27AM BLOOD CRP-15.3*
___ 02:02PM BLOOD Lactate-1.0
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. ARIPiprazole 5 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO DAILY
4. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
5. Gabapentin 1200 mg PO TID
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Severe
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
8. LORazepam 1 mg PO Q6H:PRN anxiety
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Naproxen 500 mg PO Q12H:PRN Pain - Mild
11. Omeprazole 40 mg PO DAILY
12. oxaprozin 1200 mg oral DAILY
13. Pramipexole 0.25 mg PO QHS
14. Prazosin 1 mg PO QHS
15. Sertraline 200 mg PO DAILY
16. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
1 puff inhaled by mouth once daily
17. Venlafaxine XR 300 mg PO DAILY
18. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
19. Vitamin D 1000 UNIT PO DAILY
20. Vitamin D ___ UNIT PO 1 CAPSULE BY MOUTH ONCE A WEEK FOR A
TOTAL OF 12 WEEKS
21. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
22. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. CefePIME 2 g IV Q12H
2. Acetaminophen 1000 mg PO Q8H
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
5. ARIPiprazole 5 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
8. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
9. Gabapentin 1200 mg PO TID
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation 1 puff inhaled by mouth once daily
11. LORazepam 1 mg PO Q6H:PRN anxiety
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. oxaprozin 1200 mg oral DAILY
15. Pramipexole 0.25 mg PO QHS
16. Prazosin 1 mg PO QHS
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
18. Sertraline 200 mg PO DAILY
19. Venlafaxine XR 300 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. Vitamin D ___ UNIT PO 1 CAPSULE BY MOUTH ONCE A WEEK FOR
A TOTAL OF 12 WEEKS
22. HELD- Naproxen 500 mg PO Q12H:PRN Pain - Mild This
medication was held. Do not restart Naproxen until cleared by
your surgeon.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left knee wound dehiscence
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: Frontal and lateral views
INDICATION: History: ___ with left knee pain, post-op// PNA, left knee
fracture
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided PICC terminates at the cavoatrial junction. No focal
consolidation, pleural effusion, evidence of pneumothorax is seen. The
cardiac and mediastinal silhouettes are unremarkable. No overt pulmonary
edema is seen. Some degenerative changes are seen along the spine.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with left knee pain, post-op// PNA, left knee
fracture
TECHNIQUE: Three views of the left knee
COMPARISON: ___
FINDINGS:
Patient is status post left knee arthroplasty with prosthesis in anatomic
alignment. No acute fracture or dislocation is seen. Soft tissue swelling is
noted. There is a probable suprapatellar joint effusion.
IMPRESSION:
Status post right knee arthroplasty with prosthesis in anatomic alignment
without evidence of hardware complication. No acute fracture or dislocation
is seen. Probable small suprapatellar joint effusion. Soft tissue swelling.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old woman with wound dehiscence s/p left knee I D,
polyliner exchange ___, ___// please aspirate and send for cell count,
gram stain and cultures
COMPARISON: None
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
3 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a 18-gauge spinal needle was advanced into the left
knee joint. Approximately 10 cc of serosanguineous fluid was aspirated from
the joint and sent for microbiological hematological assessment.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications or complaints.
FINDINGS:
Serosanguineous joint effusion. Needle within the left knee joint.
IMPRESSION:
-Imaging Findings- as above.
-Procedure - Technically successful left knee joint aspiration
-
I Dr. ___ supervised the Resident/Fellow during the key
components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old woman s/p I D, liner excahnge // s/p revision TKA
TECHNIQUE: AP and lateral radiographs of the left knee.
COMPARISON: Left knee radiograph ___.
FINDINGS:
Patient is status post revision of left total knee arthroplasty, with liner
exchange, on ___.
A knee brace is in situ.
There is a surgical drain within the subcutaneous soft tissues along the
lateral aspect of the left lower thigh and knee joint.
The tibial and the femoral prosthesis components are well aligned and intact.
There is superficial soft tissue swelling over the left knee joint and
moderately large suprapatellar joint effusion. Additionally noted is a small
locule of air within the knee joint anteriorly, likely post-surgical in
nature.
No acute or focal destructive osseous lesion is noted.
IMPRESSION:
Revision left total knee arthroplasty. Post-surgical changes, as above. No
evidence of early post-surgical complications.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: L Knee pain, Wound eval
Diagnosed with Infct fol a proc, superfic incisional surgical site, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 97.7
heartrate: 103.0
resprate: 18.0
o2sat: 95.0
sbp: 97.0
dbp: 68.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the orthopedic surgery service for
concern of wound dehiscence s/p left total knee revision. She
was placed on IV Ancef on admission. Plastics was consulted and
recommended twice daily dressing changes of betadine to wound,
dry dressing, then 4-inch flex master. She was taken to
Interventional Radiology for a guided aspiration, which showed
WBC 2700 and RBC 150k. Knee aspiration cultures showed gram
negative rods and lactose fermenter. ID continued to follow the
patient and recommended switching Ancef to Cefepime pending
sensitivities. Plastic Reconstructive Surgery was also consulted
and they recommended twice daily dressing changes with Betadine
followed by dry sterile dressing to help wound closure.
Patient was taken back to the OR on ___ for I&D and liner
exchange.
Post-operative course was remarkable for the following:
POD#1, the patient's hematocrit was 22.9 and she was given 2
units of blood. Post-transfusion hct was 27.4. Chronic pain saw
the patient and recommended increasing her Dilaudid to ___ mg
orally every 3 hours, continuing Gabapentin 1200 mg three times
daily, and continuing Tylenol 1 gram every 8 hours. Infectious
disease recommended to continue Cefepime pending sensitivities
of OR cultures.
POD #2, hematocrit was stable at 25. CPS recommended no changes
in pain regimen and signed off. ID recommended to continue
Cefepime.
POD #3, final ID recs were to continue Cefepime x 6 weeks. Drain
was removed and Aquacel dressing was changed.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Lovenox daily for DVT
prophylaxis. The surgical dressing will remain on until POD#7
after surgery. The patient was seen daily by physical therapy.
Labs were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the dressing was
intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with no range of motion
allowed of the left lower extremity. ___ brace locked in
extension at all times.
Ms. ___ is discharged to home with services 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:
trauma-___
Major Surgical or Invasive Procedure:
___: angiography with embolization of accessory left hepatic
artery off of gastroduodenal artery
___:
1. Open reduction, internal fixation of left proximal
humerus fracture with Synthes locking lateral plate.
2. Open reduction, internal fixation of left Monteggia
fracture with plating of the ulna.
3. Open reduction, internal fixation, right ankle fracture
with screws.
4. Examination under anesthesia and closed humeral
manipulation of left transverse acetabular fracture.
History of Present Illness:
___ RHD with PMHx depression, ovarian cysts presents as
unrestrained driver after MVC at 35 mph. +LOC, but regained
consciousness at scene. Jaws of Life required to extricate her
from the vehicle. Brought to ___ where she
hemodynamically stable; work-up of head and c-spine were
negative. She did have a positive FAST with fluid in the abdomen
and pelvis. Her orthopaedic workup significant for L shoulder
fracture, L forearm fracture, L acetabular fracture and R ankle
fracture. She received 1L of fluid prior to transfer. On arrival
she was HDS, was given an additional 1L of fluid.
Past Medical History:
-ovarian cyst ___
-cyclic vomiting
-One episode of idiopathic transaminitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
Focused physical examination: ___
___: young female calm but in acute distress, in C-collar
left upper extremity:
- Skin intact; some superficial abrasions left elbow
- Visible deformity of forearm and upper arm; moderate edema
throughout upper arm and elbow/forearm
- Soft, arm and forearm, though diffusely tender
- Fires EPL/FPL/DIO; able to flex and extend wrist
- Reduced sensation axillary nerve distribution, dorsal/lateral
forearm (MC) dorsal SF and RF (ulnar)
- 2+ radial pulse, WWP fingers
right upper extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender arm and forearm
- Full, painless ROM at shoulder, elbow, wrist, and digits
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
left lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
right lower extremity:
- Skin intact
- Moderate edema and ecchymoses medial and lateral malleoli
- Tender over medial/lateral mal
- Soft, non-tender thigh and leg
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Discharge Physical Exam:
VS: T: 98.3 PO BP: 100/59 R Lying HR: 75 RR: 18 O2: 99% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, mildly tender to palpation in RUQ, no
rebound or guarding.
EXT: RLE: ace wrap c/d/I, + sensation, wiggles toes, and
capillary refill <2 seconds
LUE: in long splint, + sensation, wiggles fingers, and
capillary refill <2 seconds
LLE: warm, well-perfused, no edema
RUE: warm, well-perfused, no edema
Pertinent Results:
IMAGING:
___: Hepatic Arteriogram:
Gel-Foam and coil embolization of 2 areas of active
extravasation arising from the accessory left hepatic artery,
without evidence of active extravasation at the end of the
procedure.
___: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT:
Proximal humeral fracture through the surgical neck with medial
and superior displacement of the humeral shaft.
___: ANKLE (AP, MORTISE & LAT) RIGHT:
1. Overlying cast obscures fine bony detail.
2. Medial malleolar fracture remains displaced.
3. Again seen is a mildly displaced fracture of the lateral
aspect of the
tibial plafond.
___: PELVIS W/JUDET VIEWS (3V) PORT:
Three views of the pelvis are provided. The examination
confirms findings
from the radiograph and the CT performed on ___. There
is a
left-sided complete and complex ischial fracture, involving the
entire
acetabulum, with minimal displacement of the fractured bony
elements. A
nondisplaced complete cortical disruption posterior to the
acetabular fracture is also seen on the outside hospital CT
examination but not on the radiograph.
___ 12:00AM URINE HOURS-RANDOM
___ 12:00AM URINE UCG-NEGATIVE
___ 09:42PM ___ PO2-122* PCO2-29* PH-7.39 TOTAL
CO2-18* BASE XS--5
___ 09:42PM GLUCOSE-137* LACTATE-1.4 NA+-137 K+-3.9
CL--109*
___ 09:42PM HGB-10.3* calcHCT-31 O2 SAT-96
___ 09:42PM freeCa-1.03*
___ 09:31PM UREA N-7 CREAT-0.6
___ 09:31PM estGFR-Using this
___ 09:31PM LIPASE-53
___ 09:31PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:31PM WBC-21.1* RBC-3.68* HGB-10.0* HCT-30.1*
MCV-82 MCH-27.2 MCHC-33.2 RDW-15.3 RDWSD-46.0
___ 09:31PM PLT COUNT-286
___ 09:31PM ___ PTT-24.1* ___
___ 09:31PM ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 4000 mg daily, may change to PRN status after 1
week
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. crutch miscellaneous ONCE
RX *crutch Please provide patient with platform crutch ONCE
Disp #*1 Each Refills:*0
4. Docusate Sodium 100 mg PO BID
Hold for loose or frequent stool.
5. Gabapentin 300 mg PO TID
6. Heparin 5000 UNIT SC BID
continue until patient ambulatory
7. LORazepam 0.5 mg PO Q4H:PRN anxiety
8. OxyCODONE (Immediate Release) 20 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 20 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN for constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. wheelchair miscellaneous ONCE
RX *wheelchair Provide patient with wheelchair. ONCE Disp #*1
Each Refills:*0
12. Sertraline 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
trauma: MVC
-grade III liver laceration
-left comminuted humeral neck fracture
-right medial malleolus fracture
-right lateral talus fracture
-left comminuted acetabular fracture
-left Monteggia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT
INDICATION: History: ___ with shoulder pain, pelvic fracture also need Judet
film of the pelvis
TECHNIQUE: AP and external rotation radiographs of the left shoulder.
COMPARISON: ___ at 19:19.
FINDINGS:
A fracture of the proximal humerus through the surgical neck is noted. The
humeral shaft is medially and superiorly displaced. There are no degenerative
changes. No suspicious lytic or sclerotic lesion is identified. No
periarticular calcification or radio-opaque foreign body is seen.
IMPRESSION:
Proximal humeral fracture through the surgical neck with medial and superior
displacement of the humeral shaft.
Radiology Report
INDICATION: ___ year old woman with MVC and grade 3 liver lac// active extrav,
pseudoaneurysm
COMPARISON: CTA abdomen pelvis from ___.
TECHNIQUE: OPERATORS: Dr. ___, Radiology resident and Dr. ___
___, attending 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
200mcg of fentanyl and 4 mg of midazolam throughout the total intra-service
time of 120 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: 1% lidocaine, fentanyl, midazolam.
CONTRAST: 75 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 40 min, 126 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Accessory left hepatic angiogram.
3. Angiogram of ___ level brnches of the left hepatic artery.
4. Gel-Foam embolization of 2 areas of extravasation arising from branches of
the accessory left hepatic arteriogram.
5. Common hepatic arteriogram
6. Right common femoral arteriogram.
7. Angio-Seal closure.
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. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A ___ catheter was advanced over ___ wire into the aorta. The wire
was removed and the accessory left hepatic artery was selectively cannulated
and a small contrast injection was made to confirm position. A accessory left
hepatic arteriogram was performed. 2 areas of extravasation were identified.
An ___ renegade microcatheter and combination of double angled glide and
Transcend micro wires were used to selectively cannulate branches of the
accessory left hepatic artery. The 2 foci of extravasation were embolized
successfully with a combination of Gelfoam and 2 mm x 2 cm coils.
The ___ was then used to cannulate the common hepatic artery. A common
hepatic arteriogram was performed. No active extravasation was identified.
The catheter was then removed over the wire and the sheath was removed. A
common femoral arteriogram was performed prior to use of a closure device. An
Angioseal closure device was deployed and manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. The patient
tolerated the procedure well.
FINDINGS:
1. Accessory left hepatic artery supplying 2 areas of active extravasation
into the large liver laceration.
2. No evidence of active extravasation after Gel-Foam and coil embolization.
IMPRESSION:
Gel-Foam and coil embolization of 2 areas of active extravasation arising from
the accessory left hepatic artery, without evidence of active extravasation at
the end of the procedure.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with ankle fracture s/p reduction*** WARNING ***
Multiple patients with same last name!// fracture fracture
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right ankle.
COMPARISON: Right ankle radiograph ___ at 18:59
FINDINGS:
Overlying cast obscures fine bony detail. Re-demonstrated is a displaced
fracture of the medial malleolus. Also seen is a mildly displaced 8 mm
cortical density along the lateral aspect of the tibial plafond consistent
with fracture. There are no significant degenerative changes. The mortise is
congruent on this non stress view. No suspicious lytic or sclerotic lesion is
identified.
IMPRESSION:
1. Overlying cast obscures fine bony detail.
2. Medial malleolar fracture remains displaced.
3. Again seen is a mildly displaced fracture of the lateral aspect of the
tibial plafond.
Radiology Report
EXAMINATION: PELVIS W/JUDET VIEWS (3V)
INDICATION: History: ___ with shoulder pain, pelvic fracture*** WARNING ***
Multiple patients with same last name!// eval for fracture or dislocation.
Also need Judet film of the pelvis eval for fracture or dislocation. Also
need Judet film of the pelvis
IMPRESSION:
Three views of the pelvis are provided. The examination confirms findings
from the radiograph and the CT performed on ___. There is a
left-sided complete and complex ischial fracture, involving the entire
acetabulum, with minimal displacement of the fractured bony elements. A
nondisplaced complete cortical disruption posterior to the acetabular fracture
is also seen on the outside hospital CT examination but not on the radiograph.
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) LEFT IN O.R.
INDICATION: ORIF LEFT HUMERUS
IMPRESSION:
Fluoroscopic documentation of left humeral repair. No radiologist was present
at the procedure.
Radiology Report
EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) RIGHT IN O.R.
INDICATION: ORIF RIGHT ANKLE
IMPRESSION:
Fluoroscopic documentation of ankle fixation. No radiologist was present.
Radiology Report
EXAMINATION: HIP 1 VIEW IN O.R.
INDICATION: LEFT ACETABULAR
IMPRESSION:
Fluoroscopic documentation of left acetabular view. No radiologist was
present.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: MVC, Transfer
Diagnosed with Laceration of liver, unspecified degree, initial encounter, Car driver injured in collision w car in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is a ___ y/o F, s/p MVC with a liver
laceration and multiple orthopedic injuries including comminuted
left humeral neck fracture, right medial malleolus and lateral
talus fracture, comminuted left acetabular fracture and left
monteggia fracture. She was an unrestrained driver and was
driving at 35 mph at impact. She had LOC but regained
consciousness at the scene. She was taken to ___ where negative
C-spine and CT head were done, and positive FAST. Fractures as
above were noted on workup. Given her liver laceration she was
transferred to ___.
She was admitted to the Trauma intensive care unit for
significant hemoglobin drop and poly-trauma. Because of this,
she was emergently taken to ___ where then underwent Angio w/
embo accessory left hepatic off GDA. ___ Hct 25.7 from 30.1.
She returned to OR on ___ with orthopedics for ORIF left
humerus, right ankle, left ulnar fracture and closed tx
acetabular fracture. During the post-operative course, the
patient required 2U PRBCs which she responded to appropriately.
She was kept NPO throughout the day on ___ where she remained
hemodynamically stable. Her diet was advanced on ___ and she
was transferred out of the intensive care unit to the surgical
floor.
Her hematocrit was checked twice daily and remained constant at
22. Prophylactic subcutaneous heparin was started on ___.
Physical therapy was consulted and recommended discharge to
rehab. She was provided with a wheelchair and platform crutch
for mobilization. During her hospitalization, she reported left
shoulder pain which persisted despite repositioning. The
Orthopedic service was called and examined the surgical site.
No intervention was undertaken. Because of her continued pain,
despite narcotic analgesia, the acute pain service was consulted
and her oxycodone dose was increased. On ___, Occupational
Therapy applied a long arm splint to the LUE.
She was discharged to rehab on ___. At the time of
discharge, she was tolerating a regular diet, her pain was
controlled, she was voiding spontaneously, and mobilizing from
bed to chair with assistance. Appointments for follow-up were
made with the Acute care and Orthopedic service. Discharge
instructions were reviewd and questions answered. |
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:
EGD ___
History of Present Illness:
___ year old female with PMH endometriosis, fibromyalgia,
migraine headaches presents to the ___ ED with complaints of
RUQ and epigastric pain x 3 days. Pain is ___ and feels like
someone is "punching [her] in the gut". It was initially
intermittant, intense crampy pain with radiation to the back
lasting for ___ minutes but became constant this evening
prompting her to present to the ED for evaluation. Pain is made
worse by food, improved with pain medication which she received
in the ED. She is unable to tolerate oral intake. Reports
subjective fever however temperature max at home was 99. Also
notes nausea, no vomiting, and multiple loose stools since she
had a course of cephalexin for boils on her back. LMP 2 months
ago.
Initial VS in the ED:98.0 115/44 79 16 99%RA Exam notable for..
Labs notable for negative U/A, WBC 8.8 UCG negative
Patient was given Dilaudid 0.5mg IV x 1 and 1L IVNS. She was
given GI Cocktail with no improvment. RUQ u/s was negative for
cholelithiasis or GB thickening.
VS prior to transfer: 98.0 79 115/44 16 99%
On the floor, She reported pain improved after receiving
dilaudid in the ED and on arrival to the floor.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Endometriosis
- Fibromyalgia
- Migraine headaches
- Allergic rhinitis
- Varicella x2
Social History:
___
Family History:
Many of the females in her family have had hysterectomies for
unknown reasons. Aunt with ___ CA.
Mother: hypercholesterolemia, breast/"kidney" CA.
Father diabetes, hypertension.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.8 BP:112/61 P:59 R: 18 O2:100%RA
General: Alert young woman appaering uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, moderate tenderness in RUQ, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Genital: Normal external female genitalia, no ulcers,
significant tenderness with bimanual examination both at the
introidus and at cervix, speculum exam limited by pain, milky
cervical discharge noted, G/C chlamydia swab collected however
unsure that it was in the cervix.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Non-focal
Discharge Physical Exam:
VS- 98.___/98.1 99/54 51 100%RA
Gen- Young woman in NAD, AAox3
HEENT- MMM, PERRLA, no JVD, anicteric, pink conj
CV- s1s2 RRR no m/g/c/r
PULM- CTAB
Abd- Soft, nondistended, BS+, tenderness to palpation mainly in
epigastric region. No organomegaly.
EXT- No c.c.e
Pertinent Results:
Admission Labs:
___ 05:00PM BLOOD WBC-8.8 RBC-5.02 Hgb-12.3 Hct-37.9
MCV-75* MCH-24.4* MCHC-32.3 RDW-14.8 Plt ___
___ 05:00PM BLOOD Neuts-60.9 ___ Monos-4.9 Eos-1.5
Baso-0.5
___ 05:00PM BLOOD Glucose-96 UreaN-11 Creat-1.0 Na-140
K-3.7 Cl-108 HCO3-23 AnGap-13
___ 05:00PM BLOOD ALT-12 AST-19 AlkPhos-51 TotBili-0.2
___ 05:00PM BLOOD Lipase-77*
___ 05:00PM BLOOD Albumin-4.3
___ 11:30AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.8 Iron-79
Cholest-142
___ 11:30AM BLOOD calTIBC-306 Ferritn-62 TRF-235
___ 11:30AM BLOOD Triglyc-115 HDL-33 CHOL/HD-4.3 LDLcalc-86
.
Discharge Labs:
___ 01:00PM BLOOD WBC-6.4 RBC-5.18 Hgb-12.6 Hct-38.7
MCV-75* MCH-24.4* MCHC-32.7 RDW-15.0 Plt ___
___ 01:00PM BLOOD Glucose-124* UreaN-5* Creat-1.0 Na-138
K-3.5 Cl-107 HCO3-22 AnGap-13
___ 06:30AM BLOOD Lipase-42
___ 01:00PM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
___ 01:00PM BLOOD IgA-98
___ 01:00PM BLOOD tTG-IgA-PND
___ 04:45PM URINE Color-Straw Appear-Clear Sp ___
___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:45PM URINE UCG-NEGATIVE
.
Microbiology:
Negative H. Pylori
Negative GC/NG x2
.
Imaging:
Liver US
IMPRESSION: No evidence of cholelithiasis or cholecystitis.
.
Transabdominal Pelvic US
IMPRESSION: Normal transabdominal pelvic ultrasound. Note is
made that this is a limited study as the patient declined a
transvaginal examination.
.
CT Abdomen
IMPRESSION: Essentially normal CT of the abdomen and pelvis. No
CT evidence of pancreatitis or ovarian torsion.
.
EGD: Mild Gastritis, flattening of duodenum.
Duodenal mucosa, no diagnostic abnormalities recognized.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Gabapentin 300 mg PO TID
2. Topiramate (Topamax) 100 mg PO HS
3. Imitrex ___ mg PO DAILY:PRN Headahce
4. Cyclobenzaprine 10 mg PO HS:PRN cramping
5. Seasonique *NF* (L norgest&E estradiol-E estrad) 0.15 mg-30
mcg (84)/10 mcg (7) Oral Daily
6. Nasonex *NF* (mometasone) 50 mcg/actuation NU Daily
7. Cetirizine *NF* 10 mg Oral daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H PRN Disp #*100
Tablet Refills:*0
2. Cetirizine *NF* 10 mg Oral daily
3. Imitrex ___ mg PO DAILY:PRN Headahce
4. Nasonex *NF* (mometasone) 50 mcg/actuation NU Daily
5. Seasonique *NF* (L norgest&E estradiol-E estrad) 0.15 mg-30
mcg (84)/10 mcg (7) Oral Daily
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe pain
after tylenol, please hold for RR <10
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth Q4H PRN Disp
#*10 Tablet Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Q8H PRN Disp #*45
Tablet Refills:*0
9. Topiramate (Topamax) 100 mg PO HS
10. Cyclobenzaprine 10 mg PO HS:PRN cramping
11. Gabapentin 300 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Viral Gastroenteritis
Secondary: Fibromyalgia, Endometriosis, Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with abdominal pain.
COMPARISON: No previous exam for comparison.
FINDINGS:
LMP: Patient is unsure - likely ___.
On transabdominal imaging the uterus is normal in appearance measuring 6.9 x
4.5 x 3.3 cm. A trace of free fluid is seen within the pelvis. The ovaries
appear normal. The right ovary measures 1.2 x 1.9 x 1.6 cm. The left ovary
measures 1.4 x 2.0 x 3.5 cm. The patient declined transvaginal imaging.
IMPRESSION: Normal transabdominal pelvic ultrasound. Note is made that this
is a limited study as the patient declined a transvaginal examination.
Radiology Report
CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ woman with persistent abdominal pain, primarily
post-prandial x1 week, question pancreatitis, question ovarian torsion.
COMPARISON: Pelvic ultrasound from ___.
TECHNIQUE: Multidetector helical CT images from the lung bases to the pubic
symphysis were obtained. Sagittal and coronal reconstructions were obtained.
DLP: 486.44 mGy-cm.
FINDINGS:
The lung bases are clear. The heart is normal in size with no pericardial
effusion.
There is a tiny hypoattenuating lesion in Couinaud segment 2, which is too
small to characterize, but likely represents a small cyst. The liver is
otherwise unremarkable. The gallbladder, adrenal glands, spleen, and pancreas
are normal.
Oral contrast is noted within the bowel. There is no small bowel dilatation
or wall thickening. There is no pericolonic inflammatory change. The
appendix is normal. There is no free fluid or free air.
The bilateral kidneys demonstrate symmetric nephrograms, without
hydronephrosis. The bladder is partially distended without wall thickening.
The uterus and adnexa are unremarkable.
There is no mesenteric, retroperitoneal, or inguinal adenopathy. No
atherosclerotic vascular calcifications are noted.
There is no acute osseous abnormality.
IMPRESSION:
Essentially normal CT of the abdomen and pelvis. No CT evidence of
pancreatitis or ovarian torsion.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with CHRONIC PANCREATITIS
temperature: 98.0
heartrate: 79.0
resprate: 16.0
o2sat: 99.0
sbp: 115.0
dbp: 44.0
level of pain: 3
level of acuity: 3.0 | ___ year old female with PMH endometriosis, fibromyalgia presents
to the ED with complaints of RUQ/epigastric tenderness
.
# Abdominal pain: Sharp RUQ/epigastric pain with nausea and
worsened by food, with radiation to the back. Negative ___.
One loose stool but denies blood in stool. H/o sexual abstinence
but with a h/o endometriosis. Negative liver US in ED ruled out
gall bladder/liver pathology (along with normal LFTs). Minimally
elevated lipase. PID was considered, though she denied sexual
activity. Transabdominal US did not show ovary pathology and the
probes for GC/NG came back negative. Unlikely to be
endometriosis since pt's last LMP was 2 months ago (on birth
control), hcg neg, symptoms previously well controlled, and pain
unlike what she experiences with endometriosis. Other
possibilities included C. diff (recent antibiotic use, however
no diarrhea, pain mainly RUQ), gastroenteritis, nephrolithiasis
(negative UA, pain worsening with food is not typical), and
appendicitis (physical exam did not fit). The fact that the pain
was worse with food and it radiated to the back was concerning
for PUD and pancreatitis. Treated with IVF and bowel rest. The
lipase returned to normal the next day and the pt had no risk
factors for pancreatitis. Pt was started on clear liquids (as
well as PPI) and continued to have worsening pain with intake.
We arranged for a CT abdomen which was wnl (which eliminated
many of the possible causes) and consulted GI. GI believed that
it was viral gastroenteritis but offered to do a EGD to r/o PUD
since pain was not improving. EGD showed mild gastritis and
flattening of duodenum, biopsy done. GI recommended PPI and to
send Celiac disease labs, which were WNL. H pylori negative. We
controlled her pain and she was able to tolerate PO. We arranged
for outpt f/u at ___. At time of discharge we attributed the
pain to likely viral gastroenteritis.
.
# Migraines/Fibromyalgia: Continued on home meds. Had a migraine
while hospitalized, treated with Imitrex x1. Resolved.
. |
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:
abdominal pain
Major Surgical or Invasive Procedure:
___: ___ drainage ___
___: ___ guided drainage of smaller abscess
History of Present Illness:
___ G2P0020 POD#10 from egg retrieval at ___
transferred from ___ to ___ for abdominal pain
concerning for ___. Patient has felt generally unwell since
transfer with bloating and increased pain compared to prior
transfers. Taking Tylenol and Aleve around the clock. Last
evening around 9pm, had worsening suprapubic pain that escalated
quickly to extend to her entire abdomen. Associated with N/V
with
6 episodes of emesis last evening. Cold sweats but denies
fevers.
Denies urinary symptoms. Last BM on ___. Denies CP and SOB
but cannot take deep breath due to epigastric pain. Denies
palpitations.
Presented to OSH and pelvic US showed 7 x 6.2 x 4.5cm abscess
posterior to uterus associated with small pelvic ascites. She
was
given dose of IV ceftriaxone and flagyl and transferred to ___
for OB/Gyn.
Past Medical History:
Obstetric History: G2___
- G1: spontaneous ectopic pregnancy, ruptured, s/p left
salpingectomy (___)
- G2: ectopic pregnancy after IVF, s/p MTX treatment
Gynecologic History:
- LMP ___
- Last pap: ___
- denies abnormal Pap, fibroids, STIs
Past Medical History:
- T2DM
Past Surgical History:
- LSC cholecystomy
- Left salpingectomy (laparotomy)
- Pinky surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: stable and within normal limits; notable for stable
tachycardia
Gen: no acute distress, sitting comfortably in hospital bed;
alert and oriented to person, place, and date
CV: tachycardia; regular rhythm; no murmurs, rubs, or gallops
Resp: no acute respiratory distress, clear to auscultation
bilaterally
Abd: soft, moderately distended, normoactive bowel sounds, no
rebound or guarding. drain sites clean, dry, and intact
Ext: warm, well perfused, no tenderness or erythema, 2+ pitting
edema to knee
Pertinent Results:
___ 06:47AM BLOOD WBC-7.4 RBC-4.51 Hgb-11.5 Hct-37.6 MCV-83
MCH-25.5* MCHC-30.6* RDW-15.1 RDWSD-45.6 Plt ___
___ 03:31AM BLOOD WBC-22.9* RBC-4.40 Hgb-11.4 Hct-36.7
MCV-83 MCH-25.9* MCHC-31.1* RDW-15.3 RDWSD-46.1 Plt ___
___ 09:40PM BLOOD WBC-23.7* RBC-4.16 Hgb-10.7* Hct-34.2
MCV-82 MCH-25.7* MCHC-31.3* RDW-15.8* RDWSD-47.3* Plt ___
___ 08:00AM BLOOD WBC-27.9* RBC-4.71 Hgb-12.0 Hct-39.0
MCV-83 MCH-25.5* MCHC-30.8* RDW-15.8* RDWSD-47.8* Plt ___
___ 07:55AM BLOOD WBC-26.0* RBC-4.41 Hgb-11.4 Hct-36.4
MCV-83 MCH-25.9* MCHC-31.3* RDW-15.9* RDWSD-48.1* Plt ___
___ 06:47AM BLOOD Neuts-52 Bands-26* Lymphs-8* Monos-4*
Eos-0* ___ Metas-8* Myelos-2* AbsNeut-5.77 AbsLymp-0.59*
AbsMono-0.30 AbsEos-0.00* AbsBaso-0.00*
___ 03:31AM BLOOD Neuts-30* Bands-57* Lymphs-3* Monos-3*
Eos-1 ___ Metas-4* Myelos-2* AbsNeut-19.92* AbsLymp-0.69*
AbsMono-0.69 AbsEos-0.23 AbsBaso-0.00*
___ 07:55AM BLOOD Neuts-71 Bands-2 Lymphs-17* Monos-2*
Eos-2 ___ Metas-4* Myelos-2* NRBC-0.1* AbsNeut-18.98*
AbsLymp-4.42* AbsMono-0.52 AbsEos-0.52 AbsBaso-0.00*
___ 01:20PM BLOOD ___ PTT-30.5 ___
___ 11:30AM BLOOD ___
___ 01:20PM BLOOD ___ 06:47AM BLOOD Glucose-163* UreaN-15 Creat-0.8 Na-139
K-4.1 Cl-99 HCO3-20* AnGap-20*
___ 07:55AM BLOOD Glucose-131* UreaN-6 Creat-0.5 Na-140
K-3.5 Cl-95* HCO3-31 AnGap-14
___ 11:40AM BLOOD ALT-55* AST-31 AlkPhos-210*
___ 01:20PM BLOOD ALT-38 AST-28
___ 11:40AM BLOOD proBNP-6032*
___ 01:20PM BLOOD TSH-2.4
___ 07:02AM BLOOD Lactate-2.7*
___ 09:40AM BLOOD Lactate-1.4
___ 01:53PM BLOOD Lactate-2.8*
___ 10:08PM BLOOD Lactate-2.2*
___ 08:42AM BLOOD Lactate-2.1*
Medications on Admission:
- Metformin 500mg BID
- Levothyroxine 50mcg
- PNV
- Vitamin d
- Probiotic
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not exceed 4000 mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*2
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days
Please complete the full course as prescribed
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*24 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Take with food. Do not exceed 2400 mg in 24 hours
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*2
4. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Tubo-ovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with tachycardia and recent hyperstimulation treatment for
IVF // eval for 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 2.0 s, 0.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 4.8
mGy-cm.
2) Spiral Acquisition 3.9 s, 30.8 cm; CTDIvol = 27.2 mGy (Body) DLP = 838.1
mGy-cm.
Total DLP (Body) = 843 mGy-cm.
COMPARISON: Pelvis from ___ at 2:54 a.m.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is a 1.3 cm short axis epicardial lymph
node. Additional subcentimeter epicardial and internal mammary lymph nodes
are noted as well. No axillary, other mediastinal, or hilar lymphadenopathy
is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Bibasilar areas of atelectasis are noted. Lungs are clear
without masses or areas of parenchymal opacification. 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 for perihepatic free fluid
is seen on same day abdomen pelvis..
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Midthoracic dextroscoliosis identified.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Enlarged epicardial lymph node, nonspecific.
Perihepatic free fluid as seen on CT abdomen pelvis.
Radiology Report
INDICATION: ___ year old woman with ?___ // eval for ___
COMPARISON: CT abdomen pelvis performed at an outside hospital on ___
PROCEDURE: CT-guided drainage of a tubo-ovarian collection.
OPERATORS: Dr. ___, radiology trainee and Dr. ___,
attending radiologist. Dr. ___ personally supervised the trainee
during the key components of the procedure and reviewed and agrees with the
trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
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 plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 100 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a suture and StatLock.
The catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Total DLP (Body) = 1,399 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
3.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
66 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedural imaging of the pelvis redemonstrates a fluid collection
superior to the uterus measuring approximately 7.6 x 4.7 cm in axial
___, not substantially changed from prior allowing for differences in
technique and lack of contrast. There is small amount of ascites and
mesenteric edema also similar to prior.
Previously administered IV contrast is seen in the collecting system
bilaterally. A punctate calcification is seen in the medial aspect of the
right hepatic lobe.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p egg retrieval (___) at ___ transferred from
___ to ___ for abdominal pain c/f ___ s/p ___ guided drainage c/b
ileus // fluid overload
TECHNIQUE: Portable AP chest
COMPARISON: Chest CT ___
FINDINGS:
The lung volumes are markedly low, resulting in crowding of the
bronchovascular markings as well as magnification of the cardiac silhouette.
There are no large focal consolidations or pleural effusions. There is no
pneumothorax. The central perihilar vascular markings are borderline
prominent, which may represent mild central pulmonary vascular congestion
versus a result of low lung volumes. There is mild bibasilar atelectasis.
IMPRESSION:
Low lung volumes. No large focal consolidations or overt pulmonary edema.
Possible mild central pulmonary vascular congestion versus imaging artifact.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ s/p egg retrieval (___) with ___ s/p ___ guided
drainage c/b ileus with tachycardia and tachypnea and abd distention
concerning for sepsis. ___ evaluation? Improvement? Leakage in area of
infection? Ileus?
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: 1545.20 mGy.cm
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LOWER CHEST: There is bibasilar atelectasis at the lung bases, right greater
than left. There is no pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
Redemonstrated small amount of perihepatic fluid.
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.
Nonobstructing stone measuring 4 mm is seen in the upper pole of the left
kidney. There is no evidence of solid renal lesions or hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. 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 increased intra-abdominal ascites compared to prior (series 5, images
41, 48 and 74), as well as increased ascites layering in the pelvis.
Localized fluid collection measuring 3.2 x 3.6 cm in the right upper abdomen
may represent an early abscess formation (series 5, image 60). The appendix
is normal.
PELVIS: There is increased free fluid within the pelvis, now small to
moderate.
REPRODUCTIVE ORGANS: There is a drain visualized entering the pelvis within
the right lower abdominal wall and terminating within the cul-de-sac. The
previously seen 7.1 cm rim enhancing fluid collection has collapsed, with
possible residual collection measuring up to 3.7 cm (series 5, image 76)
posteriorly not significantly changed compared to prior.
LYMPH NODES: Prominent right diaphragmatic lymph node measures 1.1 cm in short
axis. No other abdominopelvic lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Interval placement of drain within the previously seen 7.1 cm rim enhancing
fluid collection within the cul-de-sac, which has since collapsed.
Posteriorly, additional 3.7 cm fluid collection is not significantly changed.
2. Increased pelvic fluid and ascites throughout the abdomen now small to
moderate.
3. Localized fluid collection in the right upper abdomen is not amenable to
drainage, however may represent an early abscess formation.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with ___ s/p ___ drainage c/b sepsis with
persistent tachycardia and new O2 requirement. Evaluation for PE, Pulm edema.
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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
2) Stationary Acquisition 0.8 s, 0.2 cm; CTDIvol = 13.6 mGy (Body) DLP =
2.7 mGy-cm.
3) Spiral Acquisition 3.2 s, 20.5 cm; CTDIvol = 14.9 mGy (Body) DLP = 296.9
mGy-cm.
Total DLP (Body) = 301 mGy-cm.
COMPARISON: Comparison to CTA chest from ___. Comparison to CT
abdomen/pelvis from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Unchanged appearance of a 1.3 cm epicardial
lymph node (6:55). Additional subcentimeter epicardial and internal mammary
lymph nodes are unchanged. No axillary or hilar lymphadenopathy is present.
No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Bibasilar areas of atelectasis are again noted, slightly
increased from prior study. Lungs are otherwise clear without masses or areas
of parenchymal opacification. 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. Small amount
of perihepatic fluid is better assessed on prior CT abdomen/pelvis from ___.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Unchanged appearance of an enlarged epicardial lymph node, nonspecific.
3. Bibasilar areas of atelectasis, slightly increased from prior study. No
pleural effusion.
4. Small amount of perihepatic fluid, better assessed on prior CT
abdomen/pelvis from ___.
Radiology Report
EXAMINATION: Pelvic collection drainage.
INDICATION: ___ year old woman with ___ // drain pelvic abscess and
peritoneal fluid
COMPARISON: CT ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___, radiology trainee 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 left lateral position on the CT scan table.
Limited preprocedure CT scan was performed to localize the collection. Based
on the CT findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
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 plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately ___ cc of serosanguineous fluid was aspirated with a sample sent
for microbiology evaluation. The catheter was secured by a StatLock. The
catheter was attached to a suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
Total DLP (Body) = 1,855 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preliminary scan demonstrated a hypodense collection in the presacral space
surrounding fluid, seen on the previous contrast-enhanced CT of the abdomen
and pelvis. The collection measures approximately 3.8 x 3 0 cm, not
substantially changed compared to prior study allowing for differences in
technique and lack contrast. Similar to slightly decreased extent
abdominopelvic ascites. There is pronounced soft tissue anasarca as seen
previously. Postprocedure images demonstrate a pigtail catheter along the
posterior aspect of the fluid collection.
A previously placed right anterolateral percutaneous approach pigtail catheter
is again demonstrated in grossly stable position.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with known ___ s/p ___ drainage x2, CXR
w/ atelectasis ___, respiked fever to 102.5. // New-onset pneumonia I/s/o
poor lung inflation?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ CT chest
FINDINGS:
There are low bilateral lung volumes. Bibasilar atelectasis is present as
well as pulmonary vascular congestion. No pleural effusion or pneumothorax.
The size of the cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Low bilateral lung volumes and bibasilar atelectasis. New pulmonary vascular
congestion.
Radiology Report
EXAMINATION: SECOND OPINION CT ABD/PELVIS
INDICATION: History: ___ with abd pain 10 days s/p egg retrieval, transferred
from ___ c/f ___ // confirm tubo-ovarian abscess?
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: 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:
LOWER CHEST: Visualized lung bases are clear. There is no pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no focal lesion. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent. There
is a small amount of perihepatic ascites.
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 solid renal lesions. There is no perinephric
abnormality. There is no hydronephrosis or hydroureter. A 4 mm
nonobstructive stone is seen in the upper pole left kidney (201:38). The
urinary bladder is decompressed.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement. The colon and rectum are
within normal limits. The appendix is normal. There is a small amount of
intra-abdominal ascites within the bilateral pericolic gutters tracking
inferiorly to the pelvis.
PELVIS: There is a small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is grossly within normal limits. In the
cul-de-sac, there is an irregular, rim-enhancing fluid collection measuring
7.1 x 6.0 x 5.1 cm (201:73, 202:49), which may represent a tubo-ovarian
abscess or hematoma. There appears to be a smaller fluid collection
posteriorly that measures up to 3.3 cm with a thin rim (201:75). There is
also a 1.3 cm rim-enhancing fluid collection anteriorly and slightly to the
left (201:76). The right ovary is visualized and contains a small corpus
luteum (201:77). The left ovary is inseparable from the fluid collection in
the cul-de-sac.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: No significant atherosclerotic disease is noted. There is no
abdominal aortic aneurysm.
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. Irregular, rim-enhancing fluid collection measuring 7.1 x 6.0 x 5.1 cm in
the cul-de-sac, which may represent a tubo-ovarian abscess or hematoma. Two
additional smaller collections adjacent to this dominant collection. These
are favored to arise from the left adnexa, though correlation with side of egg
retrieval is recommended.
2. Small amount abdominopelvic ascites.
3. 4 mm nonobstructive left upper pole renal stone.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.5
heartrate: 117.0
resprate: 14.0
o2sat: 93.0
sbp: 117.0
dbp: 62.0
level of pain: 8
level of acuity: 2.0 | On ___, Ms. ___ was admitted on transfer from ___ for
abdominal pain concerning for ___ in the setting of SIRS, with
new oxygen requirement and tachycardia. She underwent a CTA
which was negative for pulmonary embolism and a CT A/P
demonstrated ___ in the posterior cul-de-sac and additional
smaller collections. She was started on IV antibiotics and fluid
resuscitation and underwent ___ drainage of the posterior
cul-de-sac abscess. Abscess fluid was sent for culture and grew
pansensitive E. coli. Infectious Disease was consulted for
antibiotic choice.
A repeat CT A/P confirmed interval collapse of the ___ but noted
increased pelvic ascites and unchanged posterior abscess. She
thus underwent a repeat ___ drain placement of the posterior
abscess on ___. This fluid was again sent for culture and had
no growth to date at the time of discharge. Gram stain was
notable for polymorphonuclear leukocytes. Following this
procedure she was febrile to 102.5 and had a rising
leukocytosis. This was discussed with ___ Disease and
attributed to likely transient seeding vs inflammatory reaction
from the additional ___ procedure as the subsequent infectious
workup was unrevealing. The patient received a one-time dose of
IV vancomycin following this fever, but no additional changes
were made to her antibiotic regimen. On ___, she was
transitioned to oral antibiotics prior to discharge.
Her hospital course was complicated by tachycardia, orthopnea,
and hypoxia. An EKG showed sinus tachycardia and a chest xray
showed no pulmonary edema. Her BNP was noted to be 6032.
Medicine was consulted to assist in working up the etiology of
these symptoms. A TSH was within normal limits. She thus
underwent a TTE, which demonstrated EF >55% with mild pulmonary
HTN and question of RV free wall and apical hypokinesis with
preserved basal function. Given this finding, a repeat TTE with
contrast was performed, which demonstrated a mildly dilated RV
but normal RV free wall motion. Medicine noted a similar course
of tachycardia and sensitivity to fluid resuscitation in her
prior hospitalization, and ultimately recommended close follow
up with the patient's PCP and referral to outpatient cardiology.
Her hospital course was additionally complicated by nausea and
vomiting concerning for ileus. This resolved with conservative
management, and the patient was tolerating a regular diet,
passing flatus, and having regular bowel movements by time of
discharge.
By post-operative day 2 of the second ___ procedure, she was
tolerating a regular diet, ambulating independently, and pain
was controlled with oral medications. She remained afebrile for
>24 hours following her one-time fever and was transitioned to
oral antibiotics, which she tolerated well. She was then
discharged home in stable condition with outpatient follow-up
scheduled with infectious disease. She was recommended to follow
up closely with her PCP with referral to cardiology, and her
reproductive endocrinology provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of male with history of ESRD
s/p deceased ECD donor kidney transplant ___, DM, HTN, HLD,
CAD, a flutter recently started on warfarin 5mg daily, now
presenting with RLQ pain x 1 week and dizziness/lightheadedness
on standing.
Pt was most recently admitted on ___ - ___ for
lightheadedness. pt was monitored on telemetry without episodes
of rapid flutter. ischemic cardiac work up unrevealing. Pt saw
his cardiologist last week, who started him on warfarin for
atrial flutter.
Mr. ___ reports lightheadedness when he was walking back
from the bathroom the night prior, relieved by laying down in
bed. He reports several episodes yesterday, associated with
positional changes. He denies room spinning. He had no syncope.
He denies CP, palpitation. He denies shortness of breath, leg
pain, recent long travels. He reports that his sugars were in
the 130s today. He has not had f/c/n/v, diarrhea, dysuria. He
has not noted hematuria, BRBPR, or melena. He usu does not keep
adequate hydration, but has tried to increase intake since his
visit with his nephrologist last week.
Pt also reports RLQ pain starting last night. He attributed it
to the tight belt he was wearing yesterday. However, his abd is
still tender on palpation today. He denies d/c. He denies
erythema or swelling at site. He denies recent trauma.
In the ED initial vitals were: 99.8 70 151/81 16 99% RA.
Positive orthostatics
- Labs were significant for WBC 6 (97%N), hgb 9.7 (near recent
baseline), bicarb 17, cr at 2.0 (baseline 1.7- 1.9), Mg 1.4,
lactate 0.9, INR 1.3, UA relatively blend (small leuks, few bac)
Past Medical History:
Past Medical History: ESRD on HD (___) via a LUE AV fistula,
DM2, CAD, HTN, HLD, retinopathy, cataracts, gout, OA
Past Surgical History: Left radiocephalic AV fistula (___),
fistulogram/angioplasty of juxta-anastamotic stenosis x 4 ___, ___
Social History:
___
Family History:
Family History: His sister has diabetes. His mother died with
kidney disease after refusing dialysis.
Physical Exam:
Vitals - 97.8 150/77 52 18
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: well-healed surgical scar at RLQ noted, nondistended,
+BS, mild tenderness in RLQ, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge:
24H: 3 bouts of brady to 39, no symptoms at night. Also occured
on last admission.
PHYSICAL EXAM:
Vitals -98.3 161/71 64 20 100%
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: well-healed surgical scar at RLQ noted, nondistended,
+BS, mild tenderness in RLQ, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 06:52PM LACTATE-0.9
___ 05:40PM tacroFK-11.4
___ 01:49PM HGB-9.8* calcHCT-29
___ 01:37PM GLUCOSE-246* UREA N-35* CREAT-2.0* SODIUM-138
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-17* ANION GAP-18
___ 01:37PM estGFR-Using this
___ 01:37PM CALCIUM-9.1 PHOSPHATE-2.2* MAGNESIUM-1.4*
___ 01:37PM WBC-6.0 RBC-2.96* HGB-9.7* HCT-29.4* MCV-99*
MCH-32.7* MCHC-33.0 RDW-16.2*
___ 01:37PM NEUTS-97* BANDS-2 ___ MONOS-1* EOS-0
BASOS-0 ___ MYELOS-0
___ 01:37PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
___ 01:37PM PLT SMR-LOW PLT COUNT-151
___ 01:37PM ___ PTT-30.3 ___
___ 01:30PM URINE HOURS-RANDOM
___ 01:30PM URINE UHOLD-HOLD
___ 01:30PM URINE UHOLD-HOLD
___ 01:30PM URINE GR HOLD-HOLD
___ 01:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:30PM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 01:30PM URINE HYALINE-1*
___ 01:30PM URINE MUCOUS-RARE
Final Report
INDICATION: +PO contrast; History: ___ with fevers and RLQ pain
3 months s/p
renal xplant+PO contrast // CT A/P + PO Contrast. Abscess?
Diverticulitis or
colitis?
TECHNIQUE: Axial MDCT images were obtained through the abdomen
and pelvis
without intravenous contrast material and with oral contrast
material.
Reformatted coronal and sagittal images were obtained.
DOSE: DLP: 966 mGy-cm.
CTDIvol: 16 mGy.
COMPARISON: CT from ___.
FINDINGS:
THORAX: The visualized lung bases are clear with no pleural
effusions,
pneumothorax or focal opacities. The heart is mildly enlarged.
Coronary and
aortic valvular calcifications are extensive.
LIVER: A punctate calcification is noted in the liver (2:21).
There is no
intra or extrahepatic biliary duct dilatation.
GALLBLADDER: The gallbladder is distended and contains many
small radiopaque
gallstones. There is no pericholecystic fluid or stranding.
SPLEEN: The spleen is normal in size and shape.
PANCREAS: The pancreas is without ductal dilation or
peripancreatic fat
stranding.
ADRENALS: The adrenal glands are normal in size and shape.
KIDNEYS: The native kidneys appear atrophic. Subcentimeter
hyperdense foci
are unchanged although not completely characterized. A small
simple cyst is
also again present in the left mid pole.
A transplant kidney is noted in the right lower quadrant with
marked
perinephric stranding noted, as well as mild hydronephrosis.
The urothelium
is thickened.
BOWEL: The stomach is mildly distended with oral contrast and
is
unremarkable. The small bowel opacifies with oral contrast
without obstruction
or focal wall thickening. The large bowel contains feces without
wall
thickening or evidence of obstruction. Diverticulosis is noted
without
evidence of diverticulitis. There is no intraperitoneal free
air or free
fluid.
LYMPH NODES: There are no pathologically enlarged
retroperitoneal or
mesenteric lymph nodes by CT size criteria.
PELVIS: The bladder is relatively well distended without focal
wall
thickening. There is no pelvic free fluid. There are no
pathologically
enlarged pelvic sidewall or inguinal lymph nodes by CT size
criteria. The
rectum is unremarkable. The prostate appears mild enlarged.
VESSELS & SOFT TISSUE: There is moderateatherosclerotic disease
without
aneurysmal dilatation of the abdominal aorta. The aorta and its
major branches
are patent. There are no hernias.
BONES: There are no suspicious lytic or sclerotic osseous
lesions to suggest
malignancy. Several endplate related lytic areas suggest
Schmorl's nodes or
perhaps amyloid deposition in the setting of known renal
failure.
IMPRESSION:
1. Fat stranding around the transplanted kidney in the right
lower quadrant
with mild hydronephrosis, new compared from ___.
Possibilities include
infection, rejection or sequela of obstruction although
hydronephrosis is not
severe and can be seen with reflux.
2. Cholelithiasis.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: WED ___ 11:49 AM
ECG:
Atrial flutter with variable conduction resulting in an overall
ventricular
rate of 48 beats per minute. Borderline left axis deviation. J
point
elevation in leads V2-V3 consistent with early repolarization
variant.
Non-specific ST segment flattening in the lateral leads.
Compared to the
previous tracing of ___ the overall ventricular rate is
slower and now
bradycardic. J point elevation in the mid-precordial leads is
more prominent.
Computed QRS duration is shorter. Lateral repolarization
abnormalities are
less obscured by underlying flutter waves. An ongoing ischemic
process cannot
be excluded. Clinical correlation is suggested.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Nephrocaps 1 CAP PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. PredniSONE 5 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Sodium Bicarbonate 650 mg PO BID
12. Tacrolimus 9 mg PO Q12H
13. Vitamin D 1000 UNIT PO DAILY
14. Atovaquone Suspension 1500 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Calcium Carbonate 1000 mg PO DAILY
17. Warfarin 5 mg PO DAILY16
18. NPH 16 Units Breakfast
NPH 6 Units Dinner
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Atovaquone Suspension 1500 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Mycophenolate Mofetil 500 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. PredniSONE 5 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. NPH 16 Units Breakfast
NPH 6 Units Dinner
14. Sodium Bicarbonate 1300 mg PO BID
15. Tacrolimus 8 mg PO Q12H
16. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Autonomic Instability
Pre-renal ___
Small ureteral stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with RLQ pain s/p renal transplant in ___ // blood flow?
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
FINDINGS:
The right iliac fossa 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 frank
hydronephrosis though mild fullness of the renal pelvis is noted. There is no
perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.73 to 0.74, 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 77.1 cm/s. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Mild pelviectasis. Otherwise unremarkable. Please refer to subsequent CT of
the abdomen pelvis for further details.
Radiology Report
INDICATION: ___ with fever and weakness // PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph on ___.
FINDINGS:
Mild cardiomegaly. There is no focal consolidation, pleural effusion or
pneumothorax. The cardiomediastinal and hilar contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: +PO contrast; History: ___ with fevers and RLQ pain 3 months s/p
renal xplant+PO contrast // CT A/P + PO Contrast. Abscess? Diverticulitis or
colitis?
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
without intravenous contrast material and with oral contrast material.
Reformatted coronal and sagittal images were obtained.
DOSE: DLP: 966 mGy-cm.
CTDIvol: 16 mGy.
COMPARISON: CT from ___.
FINDINGS:
THORAX: The visualized lung bases are clear with no pleural effusions,
pneumothorax or focal opacities. The heart is mildly enlarged. Coronary and
aortic valvular calcifications are extensive.
LIVER: A punctate calcification is noted in the liver (2:21). There is no
intra or extrahepatic biliary duct dilatation.
GALLBLADDER: The gallbladder is distended and contains many small radiopaque
gallstones. There is no pericholecystic fluid or stranding.
SPLEEN: The spleen is normal in size and shape.
PANCREAS: The pancreas is without ductal dilation or peripancreatic fat
stranding.
ADRENALS: The adrenal glands are normal in size and shape.
KIDNEYS: The native kidneys appear atrophic. Subcentimeter hyperdense foci
are unchanged although not completely characterized. A small simple cyst is
also again present in the left mid pole.
A transplant kidney is noted in the right lower quadrant with marked
perinephric stranding noted, as well as mild hydronephrosis. The urothelium
is thickened.
BOWEL: The stomach is mildly distended with oral contrast and is
unremarkable. The small bowel opacifies with oral contrast without obstruction
or focal wall thickening. The large bowel contains feces without wall
thickening or evidence of obstruction. Diverticulosis is noted without
evidence of diverticulitis. There is no intraperitoneal free air or free
fluid.
LYMPH NODES: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
PELVIS: The bladder is relatively well distended without focal wall
thickening. There is no pelvic free fluid. There are no pathologically
enlarged pelvic sidewall or inguinal lymph nodes by CT size criteria. The
rectum is unremarkable. The prostate appears mild enlarged.
VESSELS & SOFT TISSUE: There is moderateatherosclerotic disease without
aneurysmal dilatation of the abdominal aorta. The aorta and its major branches
are patent. There are no hernias.
BONES: There are no suspicious lytic or sclerotic osseous lesions to suggest
malignancy. Several endplate related lytic areas suggest Schmorl's nodes or
perhaps amyloid deposition in the setting of known renal failure.
IMPRESSION:
1. Fat stranding around the transplanted kidney in the right lower quadrant
with mild hydronephrosis, new compared from ___. Possibilities include
infection, rejection or sequela of obstruction although hydronephrosis is not
severe and can be seen with reflux.
2. Cholelithiasis.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Dizziness, Weakness
Diagnosed with VERTIGO/DIZZINESS, OTHER MALAISE AND FATIGUE, ATRIAL FIBRILLATION
temperature: 99.8
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 151.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ with history of male with history of ESRD
s/p deceased ECD donor kidney transplant ___ with transplant
rejection 10 days out with baseline Cr of 1.7-1.9. Also with DM,
HTN, HLD, CAD, aflutter recently started on warfarin, now
presenting with dizziness/lightheadedness on standing and RLQ
pain x 1 week.
# Lightheadedness - Lightheadedness resolved on arrival to
floor. DDx includes inadequate hydration vs. secondary autonomic
dysufnction due to diabetes vs. sick sinus. Pt capable of PO
hydration and lightheadedness resolved on the floor. Cr
fluctuates but still within baseline--returned to baseline
without IVF. Monitored fever curve, trended WBC daily for signs
of infection
UA and UCx were werenegative.
# RLQ pain - normal renal transplanted ultrasound on admission,
however CT noted Fat stranding around the transplanted kidney in
the right lower quadrant with mild hydronephrosis, new compared
from ___. Per chart review, he had klebsiella UTI after
renal transplant, though UA blend and pt is asymptomatic with
negative cultures. Fat stranding is non-specific, in this
clinical setting.
transplant surgery felt there was a small stricture not
concerned and not inclined to do nephrogram or stent placement.
- ID Consulted and said no need for PPX for UTI.
- urine BK virus was <500
# A flutter - rate of 55 on admission. pt recently started on
warfarin by outpatient cardiologist.
- Cards consult saw while inpatient-rec to f/u with outpatient
cardiologist.
- Anticoagulated with daily 5mg Warfarin, but increased to 7.5mg
on day of discharge and had close follow up INR check.
- no indication for rate control while in patient.
- repleted electrolytes daily
# ESRD s/p ECD renal transplant: Transplant was on ___ and
was complicated by delayed graft function and brief period of
HD.
- Repeatd UA and UCx for trend--both negative for infection.
- transplanted renal ultrasound normal
- continued immunosuppresion with
Mycophenolate Mofetil 500 mg PO BID
PredniSONE 5 mg PO DAILY
Tacrolimus 8 mg PO Q12H
- Continue Atova___ Suspension 1500 mg PO DAILY
- Continue Sodium Bicarbonate 650 mg PO BID
- Daily Tacro levels |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea on exertion, acute respiratory infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is ___ F PMHx severe asthma w/ multiple admissions for
exacerbation (recently tapered off chronic prednisone in ___,
p/w fever (Tmax 102.3), cough, SOB. She reports that on ___, she noticed increased SOB, increased cough with green /
white sputum, muscle aches, and chills. She tried using her
albuterol inhaler at home with little effect. She presented to
her PCP on ___, where her resting O2 sat was 90%, Peak
flow 160 ___ 250-300). She was subsequently sent to the BI ED
for
evaluation.
In the ED, vitals were: Pain 4, T 102.9, HR 129, BP 151/75, RR
18, Pox 89% RA
Exam:
Lungs: decr air movement, expiratory wheezes b/l
Labs:
FluA PCR: Positive
COMPLETE BLOOD COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt
Ct
___ 12:00 ___
30.8*12.9 43.4218
DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm
GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso
___ 12:00 77.9* 13.1*8.30.0*0.3
0.48.36*1.400.89*0.00*0.03
RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap
___ 12:00 107*18 1.0 ___
Studies:
EKG: NSR
CXR: No acute cardiopulmonary abnormality.
They were given:
___ 10:30IVFNSStarted
___ 11:50IHIpratropium-Albuterol Neb 1 NEB
___ 12:48IHIpratropium-Albuterol Neb 1 NEB
___ 12:48POPredniSONE 40 mg
___ 13:52IHIpratropium-Albuterol Neb 1 NEB
___ 14:57IVFNS 1000 mLStopped (4h ___
___ 15:11POAcetaminophen 1000 mg
___ 15:11PO/NGOSELTAMivir 75 mg
___ 15:11IVFNSStarted
___ 18:12IHAlbuterol 0.083% Neb Soln 1 NEB
___ 21:30IVFNS 1000 mL
___ 23:01IHAlbuterol 0.083% Neb Soln 1 NEB
___ 03:02PO/NGOSELTAMivir 75 mg
___ 05:53IHAlbuterol 0.083% Neb Soln 1 NEB
___ 05:53PO/NGGuaiFENesin 10 mL
___ 08:45POCetirizine 10 mg
___ 08:45PO/NGPredniSONE 40 mg
___ 09:41PO/NGMontelukast 10 mg
___ 09:41POOmeprazole 40 mg
___ 09:41PO/NGAspirin 81 mg
___ 10:51POMetFORMIN XR (Glucophage XR) 500 mg
___ 12:20IHAlbuterol 0.083% Neb Soln 1 NEB
___ 14:44POAzithromycin 500 mg
___ 14:49PO/NGOSELTAMivir 75 mg
She remained in the ED overnight for observation, however
continued to desaturate on RA and when ambulating. She was
admitted for management. On the floor, patient reports feeling
well with no SOB on 1L NC.
REVIEW OF SYSTEMS:
==================
Endorses fever, decreased appetite, increased cough, increased
green/white sputum, diarrhea, pain in muscles and joints.
Denies headache, hemoptysis, nausa, vomiting, abdominal pain,
urinary frequency, pain with urination, rashes, dizziness,
fainting
Past Medical History:
Asthma, vertigo, DMII
Social History:
___
Family History:
- Mother (deceased): asthma, hypertension, CHF, COPD, DM
- Father (deceased, ___): myocardial infarction
- Brother (deceased, ___): myocardial infarction
- 2 sisters, 1 brother: healthy
- Son (___): asthma
- Daughter (___): healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
___ 2016Temp 98.9, BP 141 / 85HR 94RR 18O2 sat 95 RA
GENERAL: Alert and interactive. In no acute distress, with nasal
cannula in place.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Expiratory wheezing bilaterally, decreased breath sounds.
No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. Cap
refill <2s. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. ___ strength throughout. Normal sensation. Gait is
normal.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 704)
Temp: 97.7 (Tm 98.9), BP: 137/80 (119-141/73-85), HR: 92
(86-94), RR: 18, O2 sat: 93% (93-97), O2 delivery: ra, Wt: 216.4
lb/98.16 kg
GENERAL: Alert and interactive. In no acute distress, with nasal
cannula in place.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Minimal expiratory wheeze bilaterally, good air
movement. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
___ 12:00PM BLOOD WBC-10.7* RBC-4.33 Hgb-12.2 Hct-39.6
MCV-92 MCH-28.2 MCHC-30.8* RDW-12.9 RDWSD-43.4 Plt ___
___ 12:00PM BLOOD Glucose-107* UreaN-8 Creat-1.0 Na-141
K-3.7 Cl-103 HCO3-23 AnGap-15
___ 06:43AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
PERTINENT STUDIES
CHEST XRAY ___
FINDINGS:
Heart size is mildly enlarged, unchanged. The mediastinal and
hilar contours are normal. The pulmonary vasculature is normal.
Lungs are clear apart from subsegmental left lower lobe
atelectasis. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Influenza A PCR positive
DISCHARGE LABS
___ 06:43AM BLOOD WBC-8.7 RBC-4.17 Hgb-11.7 Hct-38.1 MCV-91
MCH-28.1 MCHC-30.7* RDW-13.0 RDWSD-43.9 Plt ___
___ 06:43AM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-146
K-4.0 Cl-105 HCO3-26 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Calcium Carbonate 500 mg PO Frequency is Unknown
4. Acetaminophen 325 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
6. Ascorbic Acid ___ mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Cetirizine 10 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 PRN
11. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN asthma
13. Ferrous Sulfate 325 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO BID
15. Omeprazole 40 mg PO BID
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
every six (6) hours Refills:*0
2. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY
Take 4 pills ___, then 3 pills ___, then 2 pills
___, then 1 pill ___.
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*38
Tablet Refills:*0
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Calcium Carbonate 500 mg PO TID
5. Acetaminophen 325 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. Cetirizine 10 mg PO DAILY
11. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 PRN
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
15. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN asthma
16. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
17. Montelukast 10 mg PO DAILY
18. Omeprazole 40 mg PO BID
19. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
20. TraZODone 50 mg PO QHS:PRN insomnia
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute asthma exacerbation secondary to influenza
Acute hypoxemic respiratory failure
SECONDARY DIAGNOSES:
Obstructive sleep apnea
Non-insulin-dependent diabetes
Insomnia
GERD
Hyperlipidemia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with asthma, sob, cough, body aches// eval pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is mildly enlarged, unchanged. The mediastinal and hilar contours
are normal. The pulmonary vasculature is normal. Lungs are clear apart from
subsegmental left lower lobe atelectasis. No pleural effusion or pneumothorax
is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion, ILI
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: 102.9
heartrate: 129.0
resprate: 18.0
o2sat: 93.0
sbp: 151.0
dbp: 75.0
level of pain: 4
level of acuity: 3.0 | SUMMARY STATEMENT:
====================
___ F severe asthma w/ multiple admissions for exacerbation
(recently tapered off chronic prednisone in ___, p/w fever
(Tmax 102.3), cough, SOB, muscle aches on ___, symptom onset
___. Found to be Flu A positive. Given 1 dose Azythromycin in
the ED, nebs, started on steroids at 40 mg daily, Tamiflu (___). Briefly had 1L oxygen requirement, weaned to room air,
discharged on standing nebs. Chest x-ray was unremarkable.
Patient discharged home on steroid taper. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F s/p L ureteroscopy laser lithotripsy stent placement
presented to ED with intractable flank pain radiating to
suprapubic area. No f/c. Did well postoperatively, until today
when she developed these symptoms
Past Medical History:
PMH:
Fibroids
Nephrolithiasis
PSH:
Knee surgery
L ureteroscopy laser lithotripsy stent
Meds:
Flomax
Pyridium
Percocet
Colace
ALL:
NKDA
Social History:
___
Family History:
Nephrolithiasis
Physical Exam:
AVSS
NAD
Unlabored breathing
Abdomen soft NTTP, no CVAT
Ext WWP
Pertinent Results:
___ 06:35PM GLUCOSE-107* UREA N-14 CREAT-0.9 SODIUM-139
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
___ 06:35PM WBC-12.2* RBC-4.61 HGB-14.2 HCT-40.2 MCV-87
MCH-30.9 MCHC-35.4* RDW-12.9
___ 06:35PM NEUTS-66.0 ___ MONOS-3.8 EOS-1.8
BASOS-0.9
___ 06:35PM PLT COUNT-268
___ 06:35PM URINE COLOR-DkAmb APPEAR-Hazy SP ___
___ 06:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 06:35PM URINE RBC->182* WBC-75* BACTERIA-FEW
YEAST-NONE EPI-0
___:35PM URINE MUCOUS-OCC
KUB:
Two supine views of the abdomen were provided demonstrating a
left
ureteral stent with the proximal end in the lower portion of the
left renal
pelvis and the distal portion terminating in the region of the
bladder. There
are tiny hyperdensities in the region of the left renal lower
pole, which
likely represent stones. Bowel gas pattern is unremarkable.
The bony
structures are intact.
IMPRESSION: Ureteral stent appears to be in appropriate
position.
Renal US:
FINDINGS: The right kidney measures 10.9 cm. There is no
evidence of
hydronephrosis, stone or mass. Renal echogenicity and
corticomedullary
architecture is within normal limits. The left kidney measures
10.9 cm. There
is an echogenic shadowing stone or conglomerate of smaller
stones in the lower
pole of the kidney measuring 10 x 8 x 12 mm. There is no
evidence of
hydronephrosis or mass. Renal echogenicity and corticomedullary
architecture
is within normal limits. A ureteral stent is seen in the
bladder. The
proximal portion of the stent is not visualized in the left
renal pelvis,
although this may be due to technique.
IMPRESSION:
1. Left renal stones without evidence of hydronephrosis.
2. Left ureteral stent is visualized in the bladder; however,
its proximal
portion is not seen in the renal pelvis, although this is most
likely due to
limitation of imaging technique.
Medications on Admission:
Flomax
Pyridium
Colace
Percocet
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
do not exceed greater than 4 grams daily
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 1
tablet(s) by mouth every six (6) hours Disp #*20 Tablet
Refills:*0
2. Diazepam 5 mg PO Q6H:PRN stent irritation
RX *diazepam 5 mg 1 q6h by mouth every six (6) hours Disp #*20
Tablet Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
4. Oxybutynin 5 mg PO Q8H:PRN bladder spasms, stent irritation
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*20 Tablet Refills:*0
5. Phenazopyridine 100 mg PO Q8H:PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*20 Capsule Refills:*0
7. Tamsulosin 0.4 mg PO HS
8. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Stent irritation, nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ABDOMINAL RADIOGRAPH PERFORMED ON ___
COMPARISON: Retrograde urogram from ___ and ultrasound of the kidneys
from today.
CLINICAL HISTORY: Left flank pain status post left ureteric stent and
lithotripsy on ___, assess position of the stent.
FINDINGS: Two supine views of the abdomen were provided demonstrating a left
ureteral stent with the proximal end in the lower portion of the left renal
pelvis and the distal portion terminating in the region of the bladder. There
are tiny hyperdensities in the region of the left renal lower pole, which
likely represent stones. Bowel gas pattern is unremarkable. The bony
structures are intact.
IMPRESSION: Ureteral stent appears to be in appropriate position.
Radiology Report
INDICATION: Left flank pain status post left ureteral stent and lithotripsy
on ___. Evaluate for hydronephrosis and left ureteral stent placement.
COMPARISON: CT abdomen and pelvis ___. Abdominal ultrasound ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the kidneys were
obtained.
FINDINGS: The right kidney measures 10.9 cm. There is no evidence of
hydronephrosis, stone or mass. Renal echogenicity and corticomedullary
architecture is within normal limits. The left kidney measures 10.9 cm. There
is an echogenic shadowing stone or conglomerate of smaller stones in the lower
pole of the kidney measuring 10 x 8 x 12 mm. There is no evidence of
hydronephrosis or mass. Renal echogenicity and corticomedullary architecture
is within normal limits. A ureteral stent is seen in the bladder. The
proximal portion of the stent is not visualized in the left renal pelvis,
although this may be due to technique.
IMPRESSION:
1. Left renal stones without evidence of hydronephrosis.
2. Left ureteral stent is visualized in the bladder; however, its proximal
portion is not seen in the renal pelvis, although this is most likely due to
limitation of imaging technique.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.2
heartrate: 99.0
resprate: 24.0
o2sat: 97.0
sbp: 161.0
dbp: 99.0
level of pain: 10
level of acuity: 2.0 | The patient was admitted to Dr. ___ service for
pain control. On HD #1, her pain was well controlled with oral
medications. She was afebrile with stable vital signs. She was
tolerating a regular diet, voiding, and ambulating
independedntly. She was discharged home with instructions to
schedule a stage II ureteroscopy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / atorvastatin / Beta-Blockers (Beta-Adrenergic Blocking
Agts) / IV contrast / methyldopa / adhesive tape / torsemide
Attending: ___.
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with a past medical history of CHF, GERD who
presented to the ED with chest pain.
The patient was hospitalized at ___ from ___. She
presented with cough and fevers, and was found to have the flu.
She was treated with 5 days of tamiflu 75mg once daily (dose
reduced due to renal function). She received frequent nebulizers
and an initial dose of intravenous methylprednisone given
significant wheezing. Given an initial acute kidney injury, her
home ___ was held and in that setting she developed flash
pulmonary edema and hypertensive urgency overnight ___. This
was felt related to recent steroid exposure and held home ___
dosing in background of small LV cavity and labile HTN. She
quickly stabilized on the medical floor with IV hydralazine and
briefly a non-rebreather. Her oxygenation improved over the next
several days initially diuresing with bolus dose IV lasix. She
was transitioned to lasix 20mg three times weekly. Although she
continued to cough and remained wheezy, she was eager to return
home to continue her recovery under the close watch of her 24
hour aide. Discharge weight 146lbs. Discharge sodium was 133.
Caregiver notes that pt has been gaining ___ lbs since
discharge. Pt endorses new dyspnea on exertion that improves. No
oxygen at home. No PND. This morning, pt developed chest pain
which has now resolved. Lasted a couple hours. Sharp over
center. Associated with SOB and nausea. Denies fever, belly
pain, urinary or bowel symptoms. Cut Lasix dose at discharge due
to concern for kidney function. Pt has also endorsed chronic
cough since being discharged.
Cardiologist at ___ (Dr. ___ ___ group:
___. Dr ___ PCP- out of town...Dr ___
on call: ___
Lab work in the ED showed a hyponatremia to 117. No seizures or
altered mental status. Added on urine lytes. For now patient is
hypervolemic. Received an initial dose of 20 mg of IV Lasix in
the emergency department.
In ED initial VS: 97.8 70 162/88 19 98% 2L NC
Exam: Decreased lung sounds on R. 1+ non pitting edema in legs
bilaterally
Labs significant for: Na 117
Patient was given: ASA 324, Lasix IV 20mg
Imaging notable for: Pleural effusion and pulmonary vascular
congestion on CXR.
Past Medical History:
- H/O PNA ___ ago c/b R-sided effusion requiring chest tube then
thoracotomy
- Hypertension
- LVH
- Renal artery stenosis s/p stent
- Stage I infiltrating ductal carcinoma breast CA, ER+, PR-,
___- s/p XRT/ lumpectomy
- Osteopenia, dx on a BMD of ___
- Dysfunctional uterine bleeding s/p D&C
- H/O Gangrenous appendicitis ___
- H/O C. Diff colitis
- hx of Hernia repair
- GERD
- Left elbow fracture ___ years ago
- Chest pain NOS, clean cardiac cath prior to ___ at ___
- h/o anxiety
- CHF
Social History:
___
Family History:
Mother with breast cancer
Physical Exam:
ADMISSION EXAM:
VITALS: Reviewed in MetaVision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
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
DISCHARGE EXAM:
VS: ___ ___ Temp: 97.9 PO BP: 156/71 L Lying HR: 73 RR:
20
O2 sat: 91% O2 delivery: Ra
GENERAL: elderly woman resting comfortably in bed, pleasant and
conversant in no acute distress
HEENT: legally blind bilaterally, equal in size and reactive to
light
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS:CTAB in anterior and limited posterior lung exam, no
expiratory wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: 1+ edema to ankle, trace pretibial edema, left arm
edematous, with bruising
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, CN II-XII intact. strength ___ in upper and lower
extremities
SKIN: warm and well perfused, L hand hematoma
Pertinent Results:
ADMISSION LABS:
___ 09:15PM NA+-118*
___ 06:10PM GLUCOSE-133* UREA N-16 CREAT-1.0 SODIUM-119*
POTASSIUM-4.9 CHLORIDE-81* TOTAL CO2-20* ANION GAP-18
___ 06:10PM cTropnT-<0.01
___ 02:30PM URINE HOURS-RANDOM UREA N-375 CREAT-47
SODIUM-43
___ 02:30PM URINE OSMOLAL-336
___ 01:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:52PM GLUCOSE-163* UREA N-16 CREAT-0.9 SODIUM-116*
POTASSIUM-4.9 CHLORIDE-82* TOTAL CO2-22 ANION GAP-12
___ 12:52PM ALT(SGPT)-24 AST(SGOT)-32 ALK PHOS-76 TOT
BILI-0.7
___ 12:52PM ALBUMIN-3.8
___ 12:52PM OSMOLAL-248*
___ 10:52AM ___ COMMENTS-GREEN TOP
___ 10:52AM LACTATE-1.4
___ 10:45AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:45AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-4
___ 10:42AM CK(CPK)-238*
___ 10:42AM cTropnT-0.01
___ 10:42AM CK-MB-7 ___ 10:42AM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.7
___ 10:42AM ___ PTT-25.9 ___
___ 10:00AM GLUCOSE-174* UREA N-17 CREAT-1.0 SODIUM-117*
POTASSIUM-5.3 CHLORIDE-79* TOTAL CO2-18* ANION GAP-20*
___ 10:00AM estGFR-Using this
___ 10:00AM WBC-6.7 RBC-3.52* HGB-10.2* HCT-29.2* MCV-83
MCH-29.0 MCHC-34.9 RDW-13.6 RDWSD-40.7
___ 10:00AM NEUTS-77.9* LYMPHS-12.0* MONOS-8.2 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-5.20 AbsLymp-0.80* AbsMono-0.55
AbsEos-0.02* AbsBaso-0.02
___ 10:00AM PLT COUNT-362
IMAGING:
CXR ___:
Small left pleural effusion with mild pulmonary vascular
congestion and edema.
___ consider post diuresis films to exclude an underlying
pneumonia.
CXR ___:
In comparison with the study of ___ the lung volumes
are similarly low and bibasilar densities are suggestive of
atelectatic changes. There is mild pulmonary edema, improved
from the previous study. The cardiac silhouette is enlarged.
Slight blunting of the right costophrenic angle could suggest a
small pleural effusion.
MICROBIOLOGY:
___ 10:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Cultures; Pending at time of discharge
DISCHARGE LABS:
___ 05:26AM BLOOD WBC-4.9 RBC-3.23* Hgb-9.4* Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-14.6 RDWSD-45.3 Plt ___
___ 05:26AM BLOOD Glucose-139* UreaN-21* Creat-1.2* Na-128*
K-4.9 Cl-89* HCO3-24 AnGap-15
___ 02:01AM BLOOD ALT-20 AST-31 AlkPhos-63 TotBili-0.6
___ 05:26AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 75 mg oral QHS
2. Calcium Carbonate 500 mg PO BID
3. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
4. LORazepam 0.25 mg PO BID anxiety
5. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
6. NIFEdipine (Extended Release) 90 mg PO DAILY
7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID
8. Spironolactone 25 mg PO EVERY 3 DAYS
9. Multivitamins 1 TAB PO DAILY
10. methylcellulose (laxative) 1000 mg oral BID
11. RABEprazole 20 mg oral DAILY
12. selenium 200 mcg oral DAILY
13. Aspirin 81 mg PO DAILY
14. Vitamin B Complex 1 CAP PO DAILY
15. PARoxetine 25 mg PO DAILY
16. Vitamin D 1200 UNIT PO DAILY
17. Align (Bifidobacterium infantis) 4 mg oral DAILY
18. Furosemide 20 mg PO EVERY THREE DAYS
19. Psyllium Powder 0.5 PKT PO QOD
20. Polyethylene Glycol 17 g PO QOD
21. GuaiFENesin ER 600 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Align (Bifidobacterium infantis) 4 mg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
5. Calcium Carbonate 500 mg PO BID
6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
7. GuaiFENesin ER 600 mg PO DAILY
8. irbesartan 75 mg oral QHS
9. LORazepam 0.25 mg PO BID anxiety
10. methylcellulose (laxative) 1000 mg oral BID
11. Multivitamins 1 TAB PO DAILY
12. NIFEdipine (Extended Release) 90 mg PO DAILY
13. PARoxetine 25 mg PO DAILY
14. Polyethylene Glycol 17 g PO QOD
15. Psyllium Powder 0.5 PKT PO QOD
16. RABEprazole 20 mg oral DAILY
17. selenium 200 mcg oral DAILY
18. Spironolactone 25 mg PO EVERY 3 DAYS
19. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation
DAILY
20. Vitamin B Complex 1 CAP PO DAILY
21. Vitamin D 1200 UNIT PO DAILY
22.Outpatient Lab Work
Dx: I50.31 Acute on Chronic Diastolic Heart Failure
Please Check: Basic Metabolic Profile (Sodium, Potassium,
Chloride, Bicarbonate, BUN, Sr Cr)
Please fax results to the offices of:
Dr ___: ___
___: ___
Dr. ___: ___
Phone: ___
Phone:
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis:
==================
Hypervolemic Hyponatremia
Acute on Chronic Heart Failure with Preserved Ejection Fraction
Obstructive Lung Disease
Secondary Diagnosis:
====================
Anxiety
Gastroesophageal Reflux
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: ___ with sob/// PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ is made to chest radiograph performed ___,
and ___. CT chest performed ___.
FINDINGS:
Blunting of the left costophrenic angle is likely secondary to a small left
pleural effusion. Bilateral increased interstitial markings consistent with
mild pulmonary vascular congestion and mild interstitial pulmonary edema. No
evidence of focal consolidation. Chronic emphysematous changes appear stable.
Stable mild cardiomegaly. The cardiomediastinal silhouette is unremarkable.
IMPRESSION:
Small left pleural effusion with mild pulmonary vascular congestion and edema.
___ consider post diuresis films to exclude an underlying pneumonia.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: History: ___ with pleural effusion. Rule out pneumonia post
diuresis
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___ approximately 7 hours previous
FINDINGS:
There is a small left pleural effusion, stable. There is mild pulmonary
venous congestion and mild interstitial edema, not significantly changed when
allowing for differences in technique. There is increased left retrocardiac
density, likely atelectasis however pneumonia cannot be completely excluded.
The cardiomediastinal silhouette appears similar to previous. The patient's
chin obscures the lung apices. The aorta is atherosclerotic. Degenerative
changes are seen in the shoulders.
IMPRESSION:
As above
Radiology Report
INDICATION: ___ year old woman with CHF and recent flu with hyponatremia//
Interval change
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lung apices are obscured by patient's chin. Persistent retrocardiac opacity
again seen suggestive of residual effusion with atelectasis, infection not
excluded. Pulmonary vascular congestion is similar in degree. The
cardiomediastinal silhouette is stable. Right axillary and left chest wall
clips are noted.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with obstructive lung disease, HFpEF,
hyponatremia, worsening dyspnea. Evaluate for edema vs evolution of previous
infiltrate.
TECHNIQUE: Portable chest AP.
COMPARISON: Chest radiograph from ___.
FINDINGS:
In comparison with the study of ___ the lung volumes are similarly
low and bibasilar densities are suggestive of atelectatic changes. There is
mild pulmonary edema, improved from the previous study. The cardiac
silhouette is enlarged. Slight blunting of the right costophrenic angle could
suggest a small pleural effusion.
IMPRESSION:
Mild pulmonary edema, improved from the previous study. No evidence of
consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Heart failure, unspecified, Hypo-osmolality and hyponatremia, Dyspnea, unspecified
temperature: 97.8
heartrate: 70.0
resprate: 19.0
o2sat: 98.0
sbp: 162.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Patient Summary for Admission:
================================
Ms. ___ is a ___ female with a past medical history
of HFpEF, GERD who presented to the ED with chest pain and found
to be volume overloaded and hyponatremic to 117 without acute
changes in her mental status. She was transferred to the MICU
for management of hyponatremia which was felt to be secondary to
hypervolemia in the setting of acute exacerbation of heart
failure with preserved ejection fraction. Patient was diuresed
with ___ IV lasix daily with appropriate response in sodium.
Once patient was euvolemic on exam and sodium trended back
towards patient's baseline, Ms. ___ was felt safe to be
discharged home. |
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:
___ female with history of epilepsy partialis continua,
right SDH in ___ s/p craniotomy, substance use disorder,
depression and PTSD, CAD, DM2, HTN, and agitation secondary to
medication non-compliance who presents with AMS. Per report,
patient has been very agitated at rehab today. I called the
facility to get more collateral. Per report, patient was acutely
agitated today. She is refusing to take her medications. She was
also threatening staff and was being uncooperative. The staff
felt that she needs to be evaluated in the emergency department.
There was no SI or HI.
Initial vital signs were notable for: T 96.7 HR 81 BP 115/86 RR
18 O2 sats 100% RA
Labs were notable for:
___ 03:00PM BLOOD WBC: 5.6 RBC: 3.41* Hgb: 10.0* Hct: 31.6*
MCV: 93 MCH: 29.3 MCHC: 31.6* RDW: 17.5* RDWSD: 59.1* Plt Ct:
140*
___ 03:00PM BLOOD Neuts: 43.7 Lymphs: ___ Monos: 16.1*
Eos:
3.5 Baso: 0.4 Im ___: 0.5 AbsNeut: 2.46 AbsLymp: 2.02 AbsMono:
0.91* AbsEos: 0.20 AbsBaso: 0.02
___ 03:00PM BLOOD Glucose: 181* UreaN: 9 Creat: 0.4 Na: 143
K: 3.6 Cl: 102 HCO3: 29 AnGap: 12
___ 03:00PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
Studies performed include:
[]CT Head W/O Contrast:
-No evidence of new intracranial hemorrhage or fracture.
-Stable appearance of postsurgical changes status post right
craniotomy, including right frontal dural thickening and
encephalomalacia within the right frontoparietal lobes.
[]CXR:
-Patchy atelectasis in the lung bases without focal
consolidation
to suggest pneumonia.
Patient was given:
[] CefTRIAXone
Consults: None
Upon arrival to the floor, patient is calm and cooperative with
exam. She reports that sometimes she feels confused. She also
endorses burning with urination and urinary frequency. Endorses
pain in her lower back.
Past Medical History:
- Agitation/Mood Disturbance
- Epilepsia Partialis Continua
- Post-Traumatic Stress Disorder
- Major Neurocognitive Disorder
- Hypertension
- Hyperlipidemia
- Type 2 Diabetes
- Coronary Artery Disease
- Hepatic Steatosis/Cirrhosis
- Asthma
- Normocytic Anemia
- Alcohol Use Disorder (h/o withdrawal seizures)
- Right Parietal/Frontal CVA (___)
Social History:
___
Family History:
Mother with cancer
___ uncle with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
___ Temp: 98.5 PO BP: 125/85 HR: 81 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: In no distress, lying in bed comfortably
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Breathing comfortably, clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: Oriented to person, date, and hospital. CNII-XII intact.
Moving all extremities. Increased tone on left.
PHYSICAL EXAM:
VS: 97.3 PO 137 / 85 Sitting ___ Ra
GENERAL: NAD
HEENT: PERRLA, EOMI, MMM
CV: RRR, no g/m/r
PULM: CTAB, no wheezes, no rales, no rhonchi
GI: NTND, bowel sounds present, no rebound/ no guarding
EXTREMITIES: no cyanosis, clubbing, or edema. No bony tenderness
over the L hand or wrist, no erythema or edema. ROM is
restricted. No snuff box tenderness.
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, CN II-XII grossly intact with no focal deficits. L
forearm contracted w/ hypertonicity in the digits, wrist,
forearm
and arm of the LUE.
Pertinent Results:
ADMISSION LABS:
==============
___ 03:00PM BLOOD WBC-5.6 RBC-3.41* Hgb-10.0* Hct-31.6*
MCV-93 MCH-29.3 MCHC-31.6* RDW-17.5* RDWSD-59.1* Plt ___
___ 03:00PM BLOOD Neuts-43.7 ___ Monos-16.1*
Eos-3.5 Baso-0.4 Im ___ AbsNeut-2.46 AbsLymp-2.02
AbsMono-0.91* AbsEos-0.20 AbsBaso-0.02
___ 03:00PM BLOOD Glucose-181* UreaN-9 Creat-0.4 Na-143
K-3.6 Cl-102 HCO3-29 AnGap-12
___ 05:25AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.6
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:53PM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 01:53PM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-LG*
___ 01:53PM URINE RBC->182* WBC->182* Bacteri-FEW*
Yeast-MANY* Epi-5
___ 01:53PM URINE UCG-NEG
___:53PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
==============
___ 01:30PM BLOOD WBC-5.7 RBC-3.37* Hgb-10.0* Hct-31.3*
MCV-93 MCH-29.7 MCHC-31.9* RDW-17.4* RDWSD-59.4* Plt ___
___ 01:30PM BLOOD Glucose-216* UreaN-12 Creat-0.5 Na-142
K-4.3 Cl-100 HCO3-29 AnGap-13
___ 01:30PM BLOOD Calcium-9.5 Phos-3.0 Mg-1.7
MICRO:
=====
___ 1:53 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
YEAST. >100,000 CFU/mL.
IMAGING/STUDIES/REPORTS:
=======================
NCHCT ___
1. No evidence of new intracranial hemorrhage or fracture.
2. Stable appearance of postsurgical changes status post right
craniotomy,
including right frontal dural thickening and encephalomalacia
within the right frontoparietal lobes.
CXR ___
Patchy atelectasis in the lung bases without focal consolidation
to suggest pneumonia.
NCHCT ___. No acute intracranial abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. LACOSamide 300 mg PO BID
5. Magnesium Oxide 400 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. OXcarbazepine 900 mg PO BID
8. Phenytoin (Suspension) 250 mg PO Q12H
9. Prazosin 5 mg PO QHS
10. Ramelteon 8 mg PO QHS
11. RisperiDONE 1 mg PO TID
12. Senna 8.6 mg PO BID
13. Thiamine 200 mg PO DAILY
14. Zinc Sulfate 220 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
16. Fish Oil (Omega 3) 1000 mg PO DAILY
17. Loratadine 10 mg PO DAILY
18. Milk of Magnesia 30 mL PO Q4H:PRN Constipation - Second Line
19. CefTRIAXone 2 gm IV Q24H
20. Torsemide 5 mg PO DAILY
Discharge Medications:
1. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Dose
2. Miconazole Powder 2% 1 Appl TP BID groin fungal infection
3. RisperiDONE 2 mg PO BID
4. RisperiDONE 1.5 mg PO QPM
give at 2pm
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. CefTRIAXone 2 gm IV Q24H
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. LACOSamide 300 mg PO BID
12. Loratadine 10 mg PO DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Milk of Magnesia 30 mL PO Q4H:PRN Constipation - Second
Line
16. OXcarbazepine 900 mg PO BID
17. Phenytoin (Suspension) 250 mg PO Q12H
18. Prazosin 5 mg PO QHS
19. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
20. Senna 8.6 mg PO BID
21. Thiamine 200 mg PO DAILY
22. Torsemide 5 mg PO DAILY
23. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Toxic Metabolic Encephalopathy
Urinary Tract Infection
Perineal Candidiasis
Type II Diabetes
Seizure Disorder
Hepatic Steatosis
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 AMS*** WARNING *** Multiple patients with same
last name!// r/o PNAr/o SDH
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Right PICC tip terminates in the mid SVC. Heart size is mildly enlarged but
unchanged. The mediastinal and hilar contours are normal. The pulmonary
vasculature is normal. Minimal atelectasis is seen in the lung bases without
focal consolidation. No pleural effusion or pneumothorax is seen. There are
no acute osseous abnormalities. Mild degenerative changes are noted in the
thoracic spine.
IMPRESSION:
Patchy atelectasis in the lung bases without focal consolidation to suggest
pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS. Evaluation for 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, 16.7 cm; CTDIvol = 48.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Comparison to head CT from ___.
FINDINGS:
Patient is status post right craniotomy with stable appearance of hyperdense
dural thickening along the inner table of the right frontal bone. There is
redemonstration of hypodensity in the right frontoparietal region, compatible
with encephalomalacia. There is no evidence of new hemorrhage, infarction, or
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. Subcortical and periventricular hypodensities are
nonspecific, though likely represent sequela of chronic small vessel ischemic
disease. Atherosclerotic calcification is noted in the bilateral carotid
siphons.
There is no evidence of fracture. Minimal mucosal thickening is seen within a
left ethmoid air cell. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of new intracranial hemorrhage or fracture.
2. Stable appearance of postsurgical changes status post right craniotomy,
including right frontal dural thickening and encephalomalacia within the right
frontoparietal lobes.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with fall out of bed and possible head strike//
Evaluate for intracranial process
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 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Patient is post right craniotomy with unchanged appearance of hyperdense dural
thickening along the inner bone table (604:61). A large region of
encephalomalacia involving the posterior right frontoparietal lobes,
associated with ex vacuo dilatation of the posterior right lateral ventricle,
is unchanged.
There is no evidence of acute large territorial infarction,hemorrhage,edema,or
mass-effect. There is prominence of the ventricles and sulci suggestive of
atrophy. Subcortical and periventricular white-matter hypodensities are
nonspecific, but likely represent sequela of chronic small vessel ischemic
disease.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality or fracture.
2. Unchanged encephalomalacia involving the posterior right frontoparietal
lobes.
3. Stable right craniotomy changes.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old woman with recent fall out of bed and neck pain//
Evaluate for fracture or other pathology
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 12.0 s, 18.4 cm; CTDIvol = 29.0 mGy (Body) DLP =
496.5 mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: CT C-spine from ___.
FINDINGS:
Alignment is anatomic. No fractures are identified.Mild multilevel
degenerative changes are seen, most extensive at C7-T1 and notable for
anterior osteophytes and mild loss of intervertebral disc space.There is no
prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
1. No fracture or traumatic malalignment.
2. Mild multilevel degenerative changes of the cervical spine.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) LEFT
INDICATION: ___ year old woman with recent fall out of bed// Evaluate for
acute process or fracture Evaluate for acute process or fracture
COMPARISON: None
FINDINGS:
There is no evidence of fracture or dislocation. No focal lytic or sclerotic
lesions are seen. No soft tissue calcification or radiopaque foreign bodies
identified.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with prior right-sided CVA and SDH s/p
craniotomy w/ residual deficits, epilepsy partialis continua// Fall from bed
w/head trauma, evaluate for 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, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm. DLP:
COMPARISON: Head CT ___.
FINDINGS:
Patient is status post right frontal craniotomy with unchanged appearance of
hyperdense dural thickening along the inner table (02:22). There is
encephalomalacia involving the right posterior frontal and parietal regions
with ex vacuo dilatation of the posterior right lateral ventricle is
unchanged. There is no evidence of new hemorrhage, edema, shift of normally
midline structures, or new infarction. Prominence of the ventricles and sulci
compatible with age-related involutional changes. Subcortical and
periventricular white matter hypoattenuation is nonspecific but likely
represents chronic small vessel ischemic changes.
There is partial opacification of bilateral ethmoid air cells. Remaining
paranasal sinuses are clear.. Mastoid air cells and middle ear cavities are
well aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Agitation, HI
Diagnosed with Urinary tract infection, site not specified, Restlessness and agitation
temperature: 96.7
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 115.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ female with history of
epilepsy partialis continua manifested as left arm jerking and
left facial involvement secondary to prior right-sided stroke
(___) and right SDH in ___ s/p craniotomy, substance use
disorder, depression and PTSD, hepatic steatosis v. cirrhosis,
CAD, DM2, HTN, and agitation secondary to medication
non-compliance, who presented with new episode of agitation in
the setting of medication non-compliance and UTI.
#Urinary tract infection
#Perineal Candidiasis
- Patient presented with an UTI. She was initially started on
Unasyn until urinary cultures grew Gram positives and yeast. She
was then switched to linezolid and ceftriaxone given her
previous resistance profiles. Her yeast was felt to be due to a
groin skin fungal infection, for which the patient was treated
with miconazole powder and a 1x dose of diflucan. UCx ultimately
grew staph species which was unable to be speciated. She was
transitioned to fosfomycin x2 doses to complete treatment for
her complicated UTI.
#Altered mental status
#Agitation
- Pt has had multiple admissions for similar symptoms,
previously attributed to medication noncompliance. Per rehab,
patient had been refusing medications and became increasingly
agitated. She also had a complete toxic metabolic workup that
included an UA with signs of infection and was treated as above.
Tox screen was negative. In-house the patient was intermittently
agitated and required intermittent PRN Haldol 2.5mg-5mg, which
she responded to. Her home risperidone was increased to 2mg PO
QHS, and 1 mg PO BID ___ and 1400).
#Fall
The patient had an unwitnessed fall on ___ with possible
head strike. The patient underwent NCHCT, CT C-spine, elbow, and
forearm XRs. These showed which were negative for any acute
changes. She otherwise remained stable. The patient had a second
unwitnessed fall ___ with possible head strike. The patient
underwent NCHCT which was negative.
CHRONIC ISSUES
# Seizure Disorder
# PTSD
Pt was intermittently non-compliant and refused medications.
Continued outpatient seizure meds.
# HTN
# CAD
Continued home aspirin, Lipitor, and metoprolol.
# Diabetes:
Continued insulin sliding scale in-house.
# Hepatic Steatosis
# EtOH Abuse
Continued folate and thiamine.
Greater than 30 minutes was spent in care coordination
counseling on the day of discharge.
TRANSITIONAL ISSUES
- CODE: FULL CODE (presumed)
- EMERGENCY CONTACT HCP: ___ ___
- Taper down on Risperadal as necessary.
- QTc 422 on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / flu vaccine
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ - HD Line Placement, plasmapheresis x2
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of DM type
II, recent recurrent UGIB, hypertension, now esenting with
increased fever and fatigue. Patient being admitted to he MICU
for further monitoring with babesia treatment.
Patient reports that he has been feeling poorly with increased
fatigue since before ___. He has been hospitalized several
times as documented below) for recurrent GI bleeding, and has
been transerred several times to the MICU and to rehab. Patient
continues to coplain of a low grade temperature 100.0 since
leaving on ___ aftr going to the rehab, and has been
having increasing chills for the past few days. His rehab has
continued to send blood cultures to attmpt to find an occult
bacteremia, and then sent a parasite smear at ___
which then showed a parasite percentage of 19.8%. Given
patient's history of asplenia ___ to Whipple Procedure, and
parsite burden, patient was transferred to ___ for further
evaluation
Of note, Mr. ___ has had multiple hospitalizations in the
past few months. Originally, patient was discharged on ___
after being hospitalized in the MICU for sepsis from a urinary
source, and found to have a 5 mm obstructing Right UPJ stone
causing mild hydronephrosis, had a PCN placed, then complicated
with melena. Patient had EGD, and capsule endoscopy which was
negative. He was readmitted again to the MICU on ___ again
with GI bleed, requiring 4 units of pRBC, thought to be ___ to
anastomotic ulcer at prior Whipple site given prior EGD findings
of a clean based ulcer at efferent limb of Whipple procedure. He
again was admitted on ___ for melena and repeat GI bleed, and
repeat endoscopy again showed same 1.5 cm anastomotic ulcer
clean based without active bleeding. Patient was then discharged
from the ___ ___ for lower extremity swelling found to
have DVT. Patient at that time was found to have thrombosis
extensive in the left leg involving the proximal superficial
femoral vein and left popliteal vein. It was thought to be
provoked in the setting of recent hospitalizations, and was
bridged to warfarin. That hospital course was also complicated
with ___ exchange of a perc nephrostomy tube (___), and
continued to have good urine output. Patient was found to have a
positive UTI, and nephrostomy cultures showed pseudomonas and
was placed on a course of ciprofloxacin.
In the ED, initial vitals: 98.4 0 116/50 18 95% RA
Labs were notable for WBC 20.7, Hct 7.9, Sodium 129, BUN 44,
Createinine 2.5, AST 43, T-bili 2.1, Albumin 2.2. LDH 638.
Parasite Smear: Pending
Urinalysis notable for UTI with > 182 WBC, cloudy, moderate
blood, large leuk, and 100 protein.
Lactate 1.9.
On transfer, vitals were: 98 89 141/56 18 99% RA
On arrival to the MICU, patient appears states that he has
increased fatigue.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. enies headache, sinus tenderness, rhinorrhea or
congestion. Denies ough, shortness of breath, or wheezing.
Denies chest pain, chest ressure, palpitations, or weakness.
Denies nausea, vomiting, iarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Diabetes Mellitus Type 1
2. Hypertension
3. Hyperlipidemia
4. Nephrolithiasis s/p PCN placement
5. Pyelnophritis
6. Pylorous Sparing Whipple in ___
7. Anastomic Ulcer with repeat GI bleeding in ___.
8. Babesiosis
9. CKD Stage II
10. RLE DVT
11. Complicated UTI
12. Bilateral Lower Extremity Edema
Social History:
___
Family History:
Non-contributory
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: Afebrile 125/57 89 95 27 87 kgs
GENERAL: fatigued, appearing, no acute distress. Appears very
tired. nswer questions appropriately, however closes eyes. Very
elderly ppearing.
HEENT: Sclera anicteric. AT/NC. Mucous membranes are very dry,
with entures on and up and down. No posterior exudate /
erythema.
Lungs: Very poor inspiratory effort on both anterior /
posterior.
CV: RRR, S1, S2. No extra sounds heard.
Abdomen: Tenderness in the RLQ, around his right perc
nephrostomy ite. No hepatomegaly appreciated, negative murphys..
Extremities:Right PICC line in place.
Warm, pefused, 1+ pulses in the extremities. There is some pedal
dema, in the feet and mid shin.
Neuro: CN II-IXI grossly intact.
========================
DISCHARGE PHYSICAL EXAM:
========================
Weight: 89.0 kg (bed)
VS: T 98.6F BP 115/48 mmHg P 79 RR 18 O2 97% RA
General: Comfortable, pleasant man, appearing his stated age in
NAD.
HEENT: EOMs intact; anicteric sclerae.
Neck: Supple, no JVD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l. No wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended. NABS. No organomegaly.
Back: R nephrostomy tube in place, c/d/I, draining clear urine.
GU: No Foley.
Ext: Warm and well-perfused. Trace edema. 2+ pulses.
Neuro: A&Ox3. CNs II-XII grossly intact.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 03:42PM BLOOD WBC-20.7*# RBC-3.02* Hgb-7.9* Hct-25.7*
MCV-85 MCH-26.2 MCHC-30.7* RDW-21.1* RDWSD-60.1* Plt ___
___ 03:42PM BLOOD Neuts-80* Bands-0 Lymphs-8* Monos-10
Eos-0 Baso-0 ___ Myelos-0 Plasma-2* AbsNeut-16.56*
AbsLymp-1.66 AbsMono-2.07* AbsEos-0.00* AbsBaso-0.00*
___ 03:42PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-1+ Ovalocy-1+
Target-1+ Schisto-OCCASIONAL Burr-1+ Tear Dr-1+ Acantho-1+
___ 01:43AM BLOOD ___ PTT-47.3* ___
___ 01:43AM BLOOD ___
___ 03:42PM BLOOD Parst S-POSITIVE
___ 08:50PM BLOOD Ret Aut-7.15* Abs ___ 03:42PM BLOOD Glucose-119* UreaN-44* Creat-2.5* Na-129*
K-4.0 Cl-98 HCO3-20* AnGap-15
___ 03:42PM BLOOD LD(LDH)-638* DirBili-1.5*
___ 03:42PM BLOOD ALT-12 AST-43* AlkPhos-111 TotBili-2.1*
___ 03:42PM BLOOD Albumin-2.2* Calcium-8.5 Phos-3.1 Mg-1.6
___ 08:50PM BLOOD Hapto-<5*
___ 09:19PM BLOOD ___ pH-7.39
___ 04:07PM BLOOD Lactate-1.9
___ 09:19PM BLOOD freeCa-1.05*
___ 06:40AM BLOOD ANAPLASMA PHAGOCYTOPHILUM DNA,
QUALITATIVE-PND
___ 08:50PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 03:42PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 03:42PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:42PM URINE RBC-100* WBC->182* Bacteri-FEW Yeast-MANY
Epi-0
=============
INTERIM LABS:
=============
___ 01:43AM BLOOD tacroFK-5.7
___ 11:30AM BLOOD tacroFK-<2.0*
Parasitemia trend
___ 03:42PM BLOOD Parst S-POSITIVE 13.1% PARASITEMIA
___ 01:43AM BLOOD Parst S-4.0 % PARASITEMIA
___ 02:45PM BLOOD Parst S-POSITIVE 9.5% PARASITEMIA
___ 03:00AM BLOOD Parst S-POSITIVE 10.0% PARASITEMIA
___ 03:00PM BLOOD Parst S-POSITIVE 8.8% PARASITEMIA
___ BLOOD PARST S-Positive 3.2% PARASITEMIA
___ 04:55AM BLOOD Parst S-POSITIVE 0.4% PARASITEMIA
___ 06:17AM BLOOD WBC-16.0* RBC-3.15* Hgb-9.1* Hct-27.6*
MCV-88 MCH-28.9 MCHC-33.0 RDW-18.6* RDWSD-54.8* Plt ___
___ 06:40AM BLOOD WBC-12.2* RBC-2.97* Hgb-8.7* Hct-26.8*
MCV-90 MCH-29.3 MCHC-32.5 RDW-21.2* RDWSD-69.3* Plt ___
___ 02:51AM BLOOD PTT-70.7*
___ 06:49AM BLOOD ___ PTT-99.5* ___
___ 04:50AM BLOOD ___ PTT-38.5* ___
___ 11:18AM BLOOD ___ 03:00PM BLOOD Glucose-290* UreaN-45* Creat-2.4* Na-131*
K-4.1 Cl-103 HCO3-18* AnGap-14
___ 06:49AM BLOOD Glucose-104* UreaN-31* Creat-1.6* Na-133
K-4.2 Cl-102 HCO3-24 AnGap-11
___ 03:00PM BLOOD ALT-13 AST-45* LD(LDH)-450* AlkPhos-81
TotBili-0.9
___ 06:06AM BLOOD ALT-17 AST-31 LD(LDH)-265* AlkPhos-96
TotBili-0.7
___ 03:27AM BLOOD Albumin-1.6* Calcium-7.6* Phos-4.2 Mg-1.8
___ 06:40AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.7
___ 05:46AM BLOOD Hapto-29*
___ 06:49AM BLOOD Hapto-80
___ 06:40AM BLOOD Hapto-96
==============
DISCHARGE LABS
==============
___ 04:55AM BLOOD WBC-8.3 RBC-2.90* Hgb-8.6* Hct-27.0*
MCV-93 MCH-29.7 MCHC-31.9* RDW-21.0* RDWSD-70.8* Plt ___
___ 04:55AM BLOOD Neuts-33.8* ___ Monos-15.2*
Eos-2.6 Baso-1.3* Im ___ AbsNeut-2.81# AbsLymp-3.88*
AbsMono-1.26* AbsEos-0.22 AbsBaso-0.11*
___ 04:55AM BLOOD ___ PTT-41.3* ___
___ 04:55AM BLOOD Parst S-POSITIVE
___ 04:55AM BLOOD Glucose-247* UreaN-26* Creat-1.5* Na-131*
K-4.4 Cl-100 HCO3-24 AnGap-11
___ 04:55AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
___ 04:50AM BLOOD Hapto-110
===============
IMAGING/STUDIES
===============
CHEST (PORTABLE AP) (___):
FINDINGS:
Low lung volumes are again noted with crowding of the
bronchovascular
structures and bibasilar atelectasis. There is no large
effusion. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities. Right PICC tip
terminates in the mid to lower SVC.
IMPRESSION:
Low lung volumes without definite superimposed acute
cardiopulmonary process.
CTU (ABD/PEL) W/O CONTR (___):
IMPRESSION:
1. 8 mm nonobstructive stone in the right renal pelvis. No
hydronephrosis with the right percutaneous nephrostomy tube in
appropriate position.
2. Mild anasarca with trace amount of simple left upper quadrant
ascites and pelvic free fluid.
3. Small bilateral pleural effusions with adjacent atelectasis.
4. Ankylosis of the lower thoracic spine.
ECHO (___):
Conclusions
The left atrium and right atrium are normal in cavity size.
Mild symmetric left ventricular hypertrophy with normal cavity
size, and regional/global systolic function (biplane LVEF = 60
%). The estimated cardiac index is normal (>=2.5L/min/m2). 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 (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. No valvular pathology or
pathologic flow identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CHEST (PORTABLE AP) (___):
IMPRESSION:
Previous mild pulmonary edema has redistributed, otherwise
unchanged.
Moderate left lower lobe atelectasis is new. Small left pleural
effusion unchanged. Heart size top-normal, increased slightly.
Right PIC line ends in the low SVC. Right jugular line ends in
the upper SVC. No pneumothorax.
ABDOMEN (SUPINE & ERECT) (___):
Preliminary:
There is a 7 mm hyperdensity which abuts the pigtail of the
right percutaneous nephrostomy tube, which corresponds to the
renal pelvic stone seen on prior CT urogram. No evidence of
bowel obstruction.
Sacral stimulator is again seen.
EKG (___): Sinus rhythm, rate 74, RBBB
=============
MICROBIOLOGY:
=============
___ - Urine culture - YEAST. >100,000 ORGANISMS/ML.
___ - MRSA screen - POSITIVE for METHICILLIN RESISTANT STAPH
AUREUS.
___ - Lyme serology - negative
__________________________________________________________
___ 11:26 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 1:43 am BLOOD CULTURE Source: Line-Picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:42 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:42 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Radiology Report
INDICATION: ___ with known babesiosis. // pneumonia?
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
Low lung volumes are again noted with crowding of the bronchovascular
structures and bibasilar atelectasis. There is no large effusion. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities. Right PICC tip terminates in the mid to lower SVC.
IMPRESSION:
Low lung volumes without definite superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST PORT LINE/TUBE PLCT 1 EXAM
INDICATION: ___ year old man with right PICC, now s/p dialysis RIJ // RIJ
placement RIJ placement
IMPRESSION:
Right internal jugular line tip is at the level of mid SVC. Heart size and
mediastinum are stable. Minimal bibasal atelectasis present. Right PICC line
tip is at the level of lower SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ? pulm edema // ? pulm edema
IMPRESSION:
In comparison to ___ chest radiograph, mild bibasilar atelectasis
has slightly worsened. No other relevant change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pulm edema // pulm edema
IMPRESSION:
In comparison to previous radiograph of 1 day earlier, cardiomediastinal
contours are stable in appearance. Layering small to moderate right pleural
effusion and small left pleural effusion have slightly increased in size in
the interval with adjacent basilar atelectasis. No other relevant change.
Radiology Report
INDICATION: ___ year old male presents with history of Whipple in ___, now
insulin dependent, HTN, HLD who presented with general malaise, chills, found
to have a 5 mm obstructing stone in right ureteropelvic junction causing mild
hydronephrosis status post percutaneous nephrostomy with ___. Please evaluate
with stone protocol, oliguric renal failure, very poor urine output, eval for
more stone burden.
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
without intravenous contrast administration with the patient in the supine
position. The non-contrast scan was done with low radiation dose technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.9 s, 64.9 cm; CTDIvol = 4.0 mGy (Body) DLP = 259.4
mGy-cm.
Total DLP (Body) = 259 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: There are bilateral small pleural effusions with adjacent
compressive atelectasis. The heart is normal in size, and coronary artery
calcifications are seen.
Evaluation of the abdomen pelvis is limited without intravenous contrast.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Pneumobilia is noted compatible with patient's known clinical history of
status post Whipple procedure. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The patient is status post Whipple procedure, and the pancreas is
not definitely seen. There is no peripancreatic stranding.
SPLEEN: The spleen is absent, and multiple soft tissue accessory splenules in
the left upper quadrant appear similar to prior exam.
ADRENALS: The right adrenal gland is normal in size and shape, and
nodularity/bulkiness of the left adrenal gland appears similar to prior exam.
URINARY: The right percutaneous nephrostomy tube is in appropriate position
in the renal pelvis. There is no hydronephrosis bilaterally. There is a 8 mm
nonobstructive stone in the right renal pelvis (series 601b: Image 36). A
simple left renal cyst is noted (series 2:image 49). There is no perinephric
abnormality.
GASTROINTESTINAL: The patient is status post Whipple procedure, and the
stomach is unremarkable. Small bowel loops demonstrate normal caliber and
wall thickness throughout without evidence of obstruction. The colon and
rectum are within normal limits. The appendix is not visualized, though there
are no secondary findings to suggest appendicitis. There is a small amount of
simple free fluid along the left upper quadrant.
PELVIS: The urinary bladder is decompressed by a Foley catheter. There is a
small amount of simple presacral free fluid.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A
right external iliac artery is mildly enlarged measuring 13 mm (series 2:image
99).
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Ankylosis of the lower thoracic spine noted. Degenerative changes of
the lumbar spine are noted, and a T11 vertebral body hemangioma is again seen.
A sacral nerve stimulator is again noted.
SOFT TISSUES: Mild soft tissue anasarca is noted.
IMPRESSION:
1. 8 mm nonobstructive stone in the right renal pelvis. No hydronephrosis
with the right percutaneous nephrostomy tube in appropriate position.
2. Mild anasarca with trace amount of simple left upper quadrant ascites and
pelvic free fluid.
3. Small bilateral pleural effusions with adjacent atelectasis.
4. Ankylosis of the lower thoracic spine.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with severe babesiosis getting pheresis with c/f
volume overload. // please eval for edema; consolidation. please eval for
edema; consolidation.
IMPRESSION:
Compared to prior chest radiographs ___ through ___ at 04:37.
Previous mild pulmonary edema has redistributed, otherwise unchanged.
Moderate left lower lobe atelectasis is new. Small left pleural effusion
unchanged. Heart size top-normal, increased slightly.
Right PIC line ends in the low SVC. Right jugular line ends in the upper SVC.
No pneumothorax.
Radiology Report
INDICATION: ___ w/ T1DM ___ Whipple, asplenia, CKDIII w/ nephrolithiasis s/p
PCN, recent UGIB (___), HTN, RLE DVT, admitted for severe Babesiosis ___ to
blood transfusion. Evaluate for ongoing presence of stone in R renal pelvis
// Please evaluate for presence of stone in R renal pelvis
TECHNIQUE: Frontal supine radiographs of the abdomen.
COMPARISON: CT urogram dated ___
FINDINGS:
A 7 mm calcific density projecting over the region of the right renal pelvis
appears unchanged from recent CT abutting the right percutaneous nephrostomy
pigtail which is also in unchanged position. A sacral stimulator in unchanged
position in the left lower quadrant. A surgical clip is seen in the left
upper quadrant.
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
IMPRESSION:
Unchanged 7 mm stone projecting over the right renal pelvis abutting the
pigtail of the percutaneous nephrostomy.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Babesiosis
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 116.0
dbp: 50.0
level of pain: nan
level of acuity: 2.0 | ___ is an ___ gentleman with a history of
T1DM from ___ procedure, asplenia, CKDIII w/ right
obstructive nephropathy s/p PCN placement, recent upper GI bleed
(___), and hypertension, who was recently admitted for RLE DVT
and was subsequently re-admitted with B symptoms of low-grade
fever and >50 lbs weight loss <2 months.
ACTIVE ISSUES
--------------------
# Severe Babesiosis. He was found to have severe Babesiosis. It
is unclear how he contracted babesia given he has largely been
indoors in rehab. The blood bank was contacted to investigate
whether this could be a case of transfusion-related babesiosis
from recent blood transfusions; investigation is still underway
at this time. He was initially admitted to the MICU for pheresis
with RBC exchange, and he underwent two cycles. He received
antibiotic therapy with clindamycin (___), quinine
(___), and doxycycline (___), and was switched to
treatment with triple therapy atovaquone, azithromycin, and
doxycycline (please see course below, doxycycline for possible
anaplasma), with a plan to treat for 6 weeks including two weeks
from date of negative parasite burden. Lyme serologies and blood
cultures were negative. Anaplasma antibody was negative, but PCR
was pending at the time of discharge. Parasitemia of ~20% on
admission, which downtrended to 0.4% on discharge. He was
followed with frequent hemolysis labs, which were all improved
at the time of discharge. He required no further transfusion
after his RBC exchange. He was continued on iron and folate
supplementation as well as zinc supplements.
.
# ___ on CKD III. His infection and septic physiology led to the
development of ___ on his chronic kidney disease from renal
hypoperfusion to a peak Cr of 2.5, which improved to 1.5 (below
recent baseline) at the time of discharge. He was supported with
fluids and diuresis was initially held. His nephrostomy tube
output was stable, and serial imaging of his right renal pelvis
stone showed stability.
.
# Acute, decompensated diastolic heart failure. Likely due to
fluid resuscitation as above as patient was positive 11L at the
time of his transfer from the ICU, which led to decompensated
diastolic heart failure requiring 5L O2. He was intermittently
diuresed with 40 mg IV Lasix and then was allowed to
auto-diurese to a dry weight of 89.0 kg at time of discharge.
.
# Right renal pelvis stone: Patient with obstructing right renal
pelvis stone on prior admission s/p percutaneous nephrostomy
tube placement. His nephrostomy tube output remained stable this
admission. He was re-evaluated by urology on ___ who felt that
stone was stable on repeat imaging (CT on admission and KUB on
___ and thus recommended follow-up as an outpatient for
management of PCN and stone.
.
# Hyponatremia: Na of 131 on discharge. Sodium ranged from
129-134 on this admission. Stable from prior admissions. ___
have been due to autodiuresis following ___. Improving at time
of discharge. Patient would benefit from work-up of hyponatremia
as outpatient.
.
==============
CHRONIC ISSUES
==============
# Chronic Right Lower Extremity DVT: Had a prior DVT on his last
hospitalization thought to be provoked secondary to prolonged
hospitalizations. Warfarin was initially held in the setting of
sepsis and concern for DIC. He was bridged with heparin and was
discharged on warfarin 2.5 mg daily with a goal INR 2.0-3.0. INR
3.0 on day of discharge. Needs repeat INR on ___.
.
# Diabetes Mellitus, Type I. Secondary to Whipple procedure.
Continued on home glargine and humalog sliding scale. Glargine
and Humalog sliding scale increased as inpatient given elevated
sugars in the 200s-300s.
.
# Hypertension: Initially held amlodipine due to concern for
sepsis and hypotension. This was restarted at a reduced dose of
5 mg daily.
.
# Pancreatic enzyme deficiency. Secondary to Whipple procedure.
Continued on Creon TID with meals.
.
# Anemia: Baseline hemoglobin ___, thought to be secondary to
to hemolysis in the setting of babesiosis. Hemoglobin was stable
and was 8.6 g/dL at the time of discharge. He was continued on
pantoprazole 40 mg daily, sulcralfate, folate, and iron
supplements.
.
# BPH. He was continued on tamsulosin 0.4 mg qhs.
.
===================
TRANSITIONAL ISSUES
===================
# Discharge Cr: 1.7
# Discharge weight: 89.0 kg
# Antibiotic regimen. Continue current abx regimen of
atovaquone/azithromycin. Will plan to treat for 6 weeks
including at least 2 weeks from date of negative parasite burden
(through at least ___, pending tolerance of the medications.
Continue doxycycline until ___.
# Lab monitoring. Please check weekly CBC, parasite smear,
hemolysis labs (haptoglobin, LDH, Tbili), and INR. Please follow
up pending anaplasma PCR.
# Anticoagulation. Will be discharged on warfarin 2.5 mg daily.
Please check INR weekly (goal 2.0-3.0).
# Hyponatremia: Please check sodium on ___. Consider outpatient
work-up for hyponatremia if persistent as outpatient.
# EKG monitoring. The patient should undergo intermittent EKG
testing
for QTc while on macrolide therapy
# Nephrolithiasis. Will continue with PCN tube with plan for
outpatient urology follow-up.
# Medication changes. Antibiotics as above. Amlodipine
dose-reduced to 5 mg daily from 10 mg given low blood pressures.
Please titrate as outpatient. Trazodone stopped because of
potential QT prolongation with concurrent azithromycin.
# CODE: FULL
# CONTACT: Son, ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ampicillin / piperacillin-tazobactam / Amoxicillin /
levofloxacin in D5W / ceftriaxone / Iodinated Contrast- Oral and
IV Dye
Attending: ___
Chief Complaint:
Fever, transfer
Major Surgical or Invasive Procedure:
PTBD placement ___
History of Present Illness:
___ with history of ETOH cirrhosis s/p liver kidney transplant
in
___ c/b recurrent cholangitis in ___ c/b biliary stenosis at
hepatocojejunostomy resulting in secondary sclerosing
cholangitis
with grade III graft fibrosis presenting with fever.
The morning of ___ he developed fever and lightheadedness.
Fever
up to ___. He went into ___ where he was found
to be tachycardic to 123 without focal findings on exam. Labs
were concerning for liver pathology with transaminases in the
300's and Tbili to 5.4. Infectious workup was otherwise negative
with no PNA on CXR and UA without evidence of UTI. Decision was
made for transfer to ___ for admission to transplant
hepatology
to for concern of recurrent cholangitis, treated with ertapenem
prior to transfer.
In the ED, he was found to have a leukocytosis and elevated
LFT's
concerning for cholestatic picture. He was seen by Hepatology
recommending admission to transplant hepatology. He was
continued on antibiotic therapy with meropenem, given 25 g of
albumin, and given his 1 mg tacrolimus dose around midnight.
Initial vitals were:
98.4F, 78, 112/64, 18, 95% on RA
- Exam was notable for:
Gen: Elderly man, seen sitting comfortably
Pulm: CTAB no WRR, unlabored breathing
CV: RRR no MRG
HEENT: Very dry mucous membranes, PERRLA, EOMI, no scleral
icterus
Abdomen: Soft NTND, no rebound tenderness no ___ sign,
well-healed surgical scars
Extremities: FROM in all 4 extremities, 2+ pulses peripherally,
no significant edema
Skin: Warm, dry and intact
Neuro: No gross neurologic deficits, alert and oriented, moves
all extremities no obvious facial abnormalities
- Labs were notable for:
WBC 15, HGB 12.9, PLT 105
Na 140, K 4.5, Cl 106, HCO3 20, BUN 26, Cr 0.9
Alb 3.6, Tbili 6.4, AST 334, ALT 299, AP 366, Lipase 30
___ 14.1, PTT 27, INR 1.3
Lactate 1.3
UA negative for UTI
- Studies were notable for:
___ RUQUS
The left hepatic artery and left portal vein were not visualized
on today's ultrasound. Otherwise, patent hepatic vasculature
with
appropriate waveforms.
___ CXR
Aside from port-a-cath no abnormalities including no signs of
PNA.
- The patient was given:
1000 mg meropenem, 25 g albumin, 1mg tacrolimus
- Hepatology were consulted
On arrival to the floor, patient endorses the above history.
Aside from the fever he feels otherwise well. He states he
feels
similar to when he "has blockages in the liver". Denies N/V,
CP,
SOB, Abdominal pain, constipation or diarrhea.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Stage III Esophageal SCC (___) s/p XRT and
carboplatin/paclitaxel
HTN
Osteoporosis
Anemia/Leukopenia ___ chemotherapy
ETOH cirrhosis s/p Liver-Kidney Transplant (___) c/b biliary
obstruction s/p revision (___) with stage 3 liver fibrosis
Secondary sclerosing cholangitis s/p PTBD
Social History:
___
Family History:
Father with "liver disease"
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 127)
Temp: 98 (Tm 98), BP: 130/70, HR: 94, RR: 18, O2 sat: 97%,
O2
delivery: Ra
GENERAL: Older man lying in NAD. Pleasant
HEENT: PERRL, non-erythematous oropharynx
NECK: no cervical LAD in anterior or posterior chains
CV: RRR without m/g/r
PULM: CTAB with no w/c/r
ABD: Prior transplant scars present, well healed. Non-distended
abdomen. Soft, NT. +BS
EXT: No ___ edema
NEURO: AAOx3
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Older man lying in NAD. Pleasant
HEENT: PERRL, non-erythematous oropharynx
NECK: no cervical LAD in anterior or posterior chains
CV: RRR without m/g/r
PULM: CTAB with no w/c/r
ABD: Prior transplant scars present, well healed. Non-distended
abdomen. Soft, NT. +BS. PTBD capped
EXT: No ___ edema
NEURO: AAOx3
Pertinent Results:
ADMISSION LABS:
===============
___ 10:18PM URINE HOURS-RANDOM
___ 10:18PM URINE UHOLD-HOLD
___ 10:18PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-SM* UROBILNGN-8* PH-6.0
LEUK-NEG
___ 10:18PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 10:18PM URINE AMORPH-OCC*
___ 10:18PM URINE MUCOUS-RARE*
___ 09:49PM tacroFK-2.7*
___ 09:48PM LACTATE-1.3
___ 09:40PM GLUCOSE-95 UREA N-26* CREAT-0.9 SODIUM-140
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
___ 09:40PM estGFR-Using this
___ 09:40PM ALT(SGPT)-299* AST(SGOT)-334* ALK PHOS-366* TOT
BILI-6.4*
___ 09:40PM LIPASE-30
___ 09:40PM ALBUMIN-3.6
___ 09:40PM WBC-15.0* RBC-4.27* HGB-12.9* HCT-38.3* MCV-90
MCH-30.2 MCHC-33.7 RDW-13.8 RDWSD-45.1
___ 09:40PM NEUTS-91.9* LYMPHS-1.9* MONOS-5.6 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-13.81* AbsLymp-0.28* AbsMono-0.84*
AbsEos-0.00* AbsBaso-0.02
___ 09:40PM PLT COUNT-105*
___ 09:40PM ___ PTT-27.0 ___
PERTINENT STUDIES:
==================
___ Micro:
- ___ Blood Cultures: ___ bottles with GNRs
- E Coli, sensitive to augmentin, unasyn, imipenem,
ertapenem, and gentamicin.
BCx daily no growth. UCx on admission no growth.
___ Imaging LIVER OR GALLBLADDER US
1. The left hepatic artery and left portal vein were not
visualized on today's ultrasound. Otherwise, patent hepatic
vasculature with appropriate waveforms.
2. Partially visualized small right pleural effusion.
___ Imaging MRCP (MR ABD ___
Status post liver transplant and hepaticojejunostomy with mild
intrahepatic bile duct dilation slightly improved compared to
prior, but fairly extensive cholangitis appears slightly worse.
Suspected pancreatic side branch IPMNs appear similar compared
to prior. Small anterior abdominal wall hernia containing small
bowel appear similar compared to prior CT. No features of small
bowel obstruction. Subcentimeter abdominal lymph nodes appear
similar compared to prior. Right anterior thoracic wall
suspected lymph node is also stable.
___ Imaging PTC
1. Successful cholangio plasty of the HJ anastomotic stenosis
with 8 mm x 4 cm balloon.
2. Successful placement of a right anterior ___
internal-external biliary
drain.
RECOMMENDATION(S): Follow up cholangiogram in ___ weeks.
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-3.2* RBC-3.72* Hgb-11.3* Hct-33.4*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.6 RDWSD-48.0* Plt Ct-97*
___ 05:40AM BLOOD ___ PTT-30.2 ___
___ 05:40AM BLOOD Glucose-97 UreaN-24* Creat-0.9 Na-143
K-3.9 Cl-105 HCO3-28 AnGap-10
___ 05:40AM BLOOD ALT-106* AST-47* AlkPhos-353*
TotBili-4.9*
___ 05:40AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.6 Mg-1.5*
___ 05:48AM BLOOD tacroFK-3.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 1 mg PO Q12H
2. Vitamin D 1000 UNIT PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
You will take this daily. Last day is ___. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Tacrolimus 1 mg PO Q12H
5. Vitamin D 1000 UNIT PO DAILY
6.Outpatient Lab Work
Weekly labs: ___
CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS. Fax results to ATTN: ___ CLINIC -
FAX: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
#Acute cholangitis
SECONDARY DIAGNOSIS
alcoholic cirrhosis status post liver kidney transplant in ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with fever liver xplant// cholangitis? pna?
COMPARISON: Prior chest CT from ___
FINDINGS:
AP upright and lateral views of the chest provided. Port-A-Cath resides over
the right chest wall with catheter tip in the low SVC. Partially visualized
left shoulder arthroplasty. Lungs are clear bilaterally without
consolidation, effusion or pneumothorax. There are no signs of congestion or
edema. The cardiomediastinal silhouette is normal. Imaged osseous structures
are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No signs of pneumonia. Port-A-Cath noted.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Fever, history of liver transplant.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Liver or gallbladder ultrasound from ___
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation.
CHD: 2 mm
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.
Spleen: The spleen demonstrates normal echotexture.
Spleen length: 13.8 cm
Kidneys: No stones, masses, or hydronephrosis are identified in either kidney.
Right kidney: Not seen
Left kidney: 8.6 cm
Doppler evaluation: The main portal vein is patent, with flow in the
appropriate direction.Main portal vein velocity is 23.3 cm/sec. Right portal
veins are patent, with antegrade flow. The left portal vein is not seen.
The main and right hepatic arteries are patent, with appropriate waveform.
The left hepatic artery is not seen. Right, middle and left hepatic veins are
patent, with appropriate waveforms. Splenic vein and superior mesenteric vein
are patent, with antegrade flow.
Note is made of a right lower quadrant transplant kidney. There is a small
right pleural effusion.
IMPRESSION:
1. The left hepatic artery and left portal vein were not visualized on today's
ultrasound. Otherwise, patent hepatic vasculature with appropriate waveforms.
2. Partially visualized small right pleural effusion.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with ETOH cirrhosis s/p transplant ___ years ago
c/b biliary stenosis and secondary sclerosing cholangitis with history of
cholangitis presenting with fever.// Evaluate for evidence of cholangitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Prior CT abdomen done ___ and prior MRCP done ___
FINDINGS:
Lower Thorax: Enhancing presumed lymph node in the right anterior lower
thorax/pleural space demonstrates avid enhancement (series 17, image 32) but
appear similar compared to prior imaging. Small right-sided pleural effusion
and trace left-sided pleural effusion. This is minimally increased compared to
prior. Bilateral gynecomastia.
Liver: The patient is status post liver transplant and hepaticojejunostomy.
There is no hepatic steatosis. Again noted is severe atrophy of the left
hepatic lobe with associated intrahepatic bile duct dilatation. This appears
similar compared to prior. No intrahepatic abscess formation.
Biliary: Mild intrahepatic bile duct dilatation appears slightly improved
compared to prior. Areas of T2 and DWI hepatic hyperintensity with fairly
extensive linear peribiliary as well as wedge-shaped peripheral hepatic
enhancement and demonstrates progressive enhancement on more delayed imaging
in keeping with cholangitis most marked in the anterior aspect of segment 4 a
and B, segments 5 and 6.
Pancreas: Normal T1 pancreatic signal hyperintensity. Sub 5 mm T2
hyperintense cystic lesions in the pancreatic body (series 3, image 22) most
likely represent side branch IPMNs, grossly unchanged.
Spleen: Mild splenomegaly with the spleen measuring 146 mm in the craniocaudal
plane, similar compared to prior.
Adrenal Glands: Mild thickening of the lateral limb of the left adrenal
appears similar to prior. The right adrenal is normal.
Kidneys: Simple renal cortical cysts bilateral. No hydronephrosis. 2 mm
suspected right renal AML (series 11, image 27) appear similar compared to
prior.
Gastrointestinal Tract: Hepaticojejunostomy is again noted. No bowel
obstruction.
Lymph Nodes: Borderline mesenteric and retroperitoneal (aortocaval) lymph
nodes appear similar compared to prior.
Vasculature: Major vasculature are patent. Hepatic arterial and portal venous
anastomosis appear patent. Occluded left portal vein in association with
marked left hepatic atrophy.
Osseous and Soft Tissue Structures: No suspicious bony lesions. Small
anterior abdominal wall hernia containing small bowel appear similar compared
to prior. No features of bowel obstruction.
IMPRESSION:
Status post liver transplant and hepaticojejunostomy with mild intrahepatic
bile duct dilation slightly improved compared to prior, but fairly extensive
cholangitis appears slightly worse.
Suspected pancreatic side branch IPMNs appear similar compared to prior.
Small anterior abdominal wall hernia containing small bowel appear similar
compared to prior CT. No features of small bowel obstruction.
Subcentimeter abdominal lymph nodes appear similar compared to prior. Right
anterior thoracic wall suspected lymph node is also stable.
Radiology Report
INDICATION: ___ year old man with h/o liver-kidney transplant in ___ (etoh
and HRS) with roux-en-y, recurrent episodes of cholangitis requiring prior
PTBD. Transferred from ___ w/ fevers, leukocytosis, GNRs on BCx
seen there, c/f cholangitis. MRCP here w/ final read pending.// Eval for
potential drainage of cholangitis
COMPARISON: MRI of the 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 endotracheal anesthesia
MEDICATIONS: Please check anesthesia flow sheets
CONTRAST: 95 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 32 minutes, 165 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Fluoroscopic guided right anterior percutaneous transhepatic bile duct
access.
3. Right anterior cholangiogram
4. Cholangio plasty of hepaticojejunostomy stricture with 8 mm x 4 cm Conquest
balloon.
5. ___ right 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.
General endotracheal anesthesia was performed. A pre-procedure time-out was
performed per ___ protocol. The right abdomen was prepped and draped in the
usual sterile fashion.
Under Fluoroscopic guidance, a 21G Cook needle was advanced into right
anteriorbiliary system. Images of the access were stored on PACS. The initial
access was used to opacify the entire biliary system. A right anterior
horizontal short-segment duct was identified. Using a double stick technique
a second 21 gauge cook needle was advanced into the right anterior biliary
system. Once return of bilious fluid was identified, a Headliner wire was
advanced under fluoroscopic guidance towards the hepaticojejunostomy. The
inner dilator with metal stiffener were advanced over the Wire. The inner
dilator was used to opacify the biliary system and confirm anatomy. A Nitinol
Wire was advanced. This was used to cross the hepaticojejunostomy. The
Accustick was then re-assembled and reintroduced. The outer sheath was
advanced into the small bowel. Contrast was injected confirming appropriate
position. An Amplatz Wire was advanced into the small bowel. The Accustick
was exchanged for 6 ___ sheath. A pull-back cholangiogram was performed.
An antegrade cholangiogram was also performed. The decision was made to treat
the hepaticojejunostomy.
An 8 mm x 4 cm Conquest balloon was advanced over the Wire and positioned at
the hepaticojejunostomy. Cholangio plasty was performed under fluoroscopic
Guidance. Post cholangio plasty antegrade cholangiogram was performed. The
balloon and sheath were removed. A 12 ___ biliary drain was advanced over
the metal stiffener and Wire. Pigtail was formed into the jejunum. Contrast
was injected confirming appropriate position. The drain was secured with Stay
sutures and sterile dressing was applied. Patient tolerated the procedure
well without immediate complications. He was extubated and returned to
recovery.
FINDINGS:
1. No evidence of significant intrahepatic biliary
ductal dilatation did can be identified by ultrasound, but was seen on
cholangiography.
2. Fluoroscopic images demonstrate opacification of the biliary system with a
central stick. A separate needle is seen accessing a peripheral inferior
right anterior moderately dilated duct.
3. Fluoroscopic images demonstrate stenosis of the hepaticojejunostomy.s
4. Final images demonstrate appropriate positioning of the biliary drain.
IMPRESSION:
1. Successful cholangio plasty of the HJ anastomotic stenosis with 8 mm x 4
cm balloon.
2. Successful placement of a right anterior ___ internal-external biliary
drain.
RECOMMENDATION(S): Follow up cholangiogram in ___ weeks.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Fever, unspecified, Liver transplant status
temperature: 98.4
heartrate: 78.0
resprate: 18.0
o2sat: 95.0
sbp: 112.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with history of alcoholic
cirrhosis status post liver kidney transplant in ___,
complicated by multiple episodes of acute cholangitis with last
recurrence in ___, as well as biliary stenosis at the
hepaticojejunostomy resulting in secondary sclerosing
cholangitis with grade 3 graft fibrosis, who presented to
___ with fevers and E. coli bacteremia ___ to
cholangitis. He was transferred here for further management.
MRCP demonstrated findings consistent with acute cholangitis and
he underwent interventional radiology PTBD placement on ___.
Patient will be treated with ertapenem for 4 total weeks and
discharged with PTBD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with history of HLD, HTN, epilepsy s/p left
temporal lobectomy who presents to ED from clinic today for
syncope and EKG with c/f ACS.
Patient reports episode of syncope this am while poring cup of
coffee. Patient does not remember passing out but woke up on the
floor after an unknown amount of time. Patient friend came by
later and reported that patient appeared pale, her eyes were
moving "side to side", and she had difficulty walking appearing
"drunk". She denied any symptoms prior to episode. Afterwards
she
endorses heart was racing and chest pain but denied any
confusion
or postictal state. Denied incontince or tongue biting.
2 prior episodes of syncope few months ago where she "collapsed"
to the floor without any prodrome symptoms. She reported feeling
fine after each episode. LOC lasted for a few minutes and she
did
not seek medical care.
In PCP office she was hypotensive to 82/54 and EKG with c/f ST
depression in inferior leads. She was given ASA 325 and
transferred to ED for further evaluation.
In the ED:
Initial vital signs were: HR95, BP162/126, RR19, 97% 2L NC, of
note pt was hypotensive to 70/45 she was given fluids and BP
improved to 102/53.
Labs were notable for:
Trop <0.01
D-dimer 207
Lactate 1.2
Cr 1.6 (baseline ___
WBC 6.1 (86% neutrophils)
Studies performed include:
EKG: NSR, Rate 94, q waves in I, II, III, Poor R wave
progression. No STE, No STD (Q waves and poor R progression
present in ___.
CXR: no acute cardio pulm process
TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%). There is no left ventricular outflow obstruction at rest
or
with Valsalva. 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 but aortic stenosis is not present. Trace
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, no major change
Patient also had stress test that was pending read at time of
transferred to floor.
Patient was given:
___ 11:52 IVF NS ( 1000 mL ordered)
Consults: none
Vitals on transfer: HR82, BP 123/60, RR19, 96% RA
Upon arrival to the floor, the patient recounts history
documented above. She told us that this morning she was in the
normal state of health when she went to get coffee and then fell
down in the kitchen. She is unable to say if she had
lightheadedness or dizziness prior to this fall but she is sure
that she didn't hit her head or loose consciousness. She sat on
the floor for a few minutes and then stood up slowly. She says
that she had a rapid heart rate and a sharp pain in ___
her
chest. She denies any urinary incontinence or tongue biting. She
also denies any double vision, focal weakness, paresthesias,
difficulty walking or speaking, or dizziness. She denies any
fevers, chills, night sweats, SOB, cough, abdominal pain,
N/V/D/C, dysuria, or swelling in her legs. She denies any
changes
in her medications or eating habits recently. She denies any
prior history of MI or heart failure. Currently she denies any
chest pain, sob, diaphoresis, or dizziness with standing.
Review of Systems:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
- HTN
- Hypothyroidism
- Anxiety
- HLF
- H/O partial epilepsy s/p left temporal lobectomy ___
- Mild developmental impairment
Surgical
- Right breast lumpectomy
- Parotid gland tumor resection
- Temporal lobectomy ___
Social History:
___
Family History:
No history cancer. No premature CAD
Physical Exam:
Admission Physical Exam:
==============
VITALS:T98.2, BP 142/78, HR 80, RR 20, 98%RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Sclera anicteric, EOMI,
PERRLA.
MMM, neck supple, no carotid bruits, no JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. II/IV
diastolic murmur best heard at ___.
LUNGS: Breathing comfortably on room air, Clear to auscultation
bilaterally No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: +BS, non distended, non-tender to deep palpation in all
four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm and well perfused, no clubbing, cyanosis, or edema,
NEUROLOGIC:AOX3, EOMI, PERRLA, Right nasolabial fold flattening
(per friend face looks normal), tongue midline, palate elevates
bilaterally, sensation intact V1-V3, hearing intact, speech
fluent without dysarthria, ___ shoulder strength.
___ strength throughout upper and lower extremities. Paratonia
throughout, sensation intact to light touch throughout.
2+ RUE reflexes, 3+ elbow, and biceps, 2+ right patella, 3+ left
patella, 3+ bilateral Achilles, +bilateral cross adductors, no
clonus, negative Hoffmans bilaterally
FTN fast and smooth, high frequency tremor in left upper
extremity. No asterixis.
Discharge Exam:
===============
Vitals: 99 PO 148 / 87 99 18 98 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, PERRLA
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. soft
systolic murmur
LUNGS: Breathing comfortably on room air, Clear to auscultation
bilaterally No wheezes, rhonchi or rales.
ABDOMEN: +BS, non distended, non-tender
EXTREMITIES: No clubbing, cyanosis, or edema
NEUROLOGIC:AOX3, speech fluent without dysarthria
Pertinent Results:
LABS:
=====
___ 11:00AM BLOOD WBC-6.1 RBC-4.29 Hgb-12.8 Hct-37.9 MCV-88
MCH-29.8 MCHC-33.8 RDW-12.3 RDWSD-39.3 Plt ___
___ 06:42AM BLOOD WBC-3.6* RBC-4.18 Hgb-12.4 Hct-37.3
MCV-89 MCH-29.7 MCHC-33.2 RDW-12.5 RDWSD-40.9 Plt ___
___ 11:00AM BLOOD Neuts-86.6* Lymphs-8.6* Monos-3.5*
Eos-0.3* Baso-0.7 Im ___ AbsNeut-5.24 AbsLymp-0.52*
AbsMono-0.21 AbsEos-0.02* AbsBaso-0.04
___ 12:25PM BLOOD ___ PTT-27.0 ___
___ 11:00AM BLOOD Glucose-145* UreaN-23* Creat-1.6* Na-137
K-4.0 Cl-97 HCO3-22 AnGap-18
___ 06:42AM BLOOD Glucose-85 UreaN-11 Creat-0.9 Na-143
K-4.0 Cl-105 HCO3-25 AnGap-13
___ 11:00AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-4 cTropnT-<0.01
___ 11:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2
___ 04:03PM BLOOD D-Dimer-207
___ 07:15PM BLOOD TSH-1.7
___ 03:25PM BLOOD Lactate-1.2
STUDIES
=======
___ Tc-99m Sestamibi Stress:
FINDINGS: Left ventricular cavity size is normal
There is soft tissue attenuation of the anterior wall and apex,
which is
corrected on attenuation correction. Otherwise, rest and stress
perfusion images
reveal uniform tracer uptake throughout the left ventricular
myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 79%.
IMPRESSION: Normal ejection fraction and wall motion. Normal
left ventricular
cavity size.
No focal perfusion defect.
___ regadenoson stress:
INTERPRETATION: This ___ year old woman with BMI of 36.9 and h/o
HTN
and HL was referred to the lab for evaluation of syncope and
chest
discomfort. She was infused with 0.4 mg of regadenoson over 20
seconds.
No chest, arm, neck or back discomfort reported. No significant
ST
segment changes noticed. Rhythm was sinus with no ectopy.
Appropriate HR
and BP response to the infusion. Aminophylline not given to the
patient
as she is having a long history of seizure and did not report
any
regadenoson -induced adverse reactions.
IMPRESSION : No anginal symptoms or ischemic ST segment changes.
Nuclear report sent separately.
CXR ___: No acute cardiopulmonary abnormality.
CT head ___:
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of acute
territorial
infarction.
2. Left frontotemporal craniotomy changes including left
temporal
encephalomalacia from prior lobectomy are noted.
TTE ___:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%). There is no left ventricular outflow obstruction at rest
or with Valsalva. 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 but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, no major change.
EEG ___: formal read pending, reportedly negative
___ 11:58 pm URINE Site: NOT SPECIFIED Source:
___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Terazosin 5 mg PO QHS
2. Lisinopril 40 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. PARoxetine 20 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. PARoxetine 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Syncope
Secondary: Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain and sycnope// effusion? edema? pna?
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
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 HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with HTN, HLD, h/o epilepsy s/p lobectomy, p/w
? syncope, found to have hyperreflexia on LUE// r/o bleed
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 9.0 s, 15.8 cm; CTDIvol = 47.4 mGy (Head) DLP =
746.1 mGy-cm.
2) Sequenced Acquisition 2.0 s, 3.5 cm; CTDIvol = 47.4 mGy (Head) DLP =
165.8 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: MRI of the brain dated ___, and ___.
FINDINGS:
Left frontotemporal craniotomy changes including left temporal
encephalomalacia from prior lobectomy are noted which appear grossly unchanged
since the prior brain MRI exam. There is unchanged ex vacuo dilatation of the
left lateral ventricle. There is no evidence of new areas of ischemia,
intracranial hemorrhage or mass effect.
No fractures are seen. There is moderate mucosal thickening of the ethmoid
air cells, more significant on the right. The remainder of the visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear, soft tissue density along the left external A2 canal and is
consistent with cerumen. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of acute territorial
infarction.
2. Left frontotemporal craniotomy changes including left temporal
encephalomalacia from prior lobectomy are noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse, Chest pain, unspecified, Acute kidney failure, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 1
level of acuity: 1.0 | ___ with history of HTN and epilepsy s/p left temporal lobectomy
who presented from PCP office after multiple recent syncopal
episodes. Per report, BP was ___ in outpatient office, and
she was sent to the ED.
#Syncope
Troponins negative x2, EKG was showed q waves and poor R wave
progression that had been present previously, pharmacological
stress test with nuclear imaging was negative, and the patient
had no anginal symptoms or EKG changes. No significant events on
telemetry were noted. TTE showed no significant valve disease,
no WMA, and no notable change since ___. D dimer negative. 24
hour EEG with no events. CT head negative. She was given IVFs
and had no further syncopal episodes while inpatient. Thought to
be secondary to antihypertensives exacerbated by hypovolemia,
particularly as her ___ and symptoms improved with IV hydration.
She continued to have intermittent postural tachycardia
associated with no symptoms, blood pressure change or hypoxemia.
Her home lisinopril, HCTZ carvedilol and terazosin were held,
and she remained normotensive. She was discharged on carvedilol
at a reduced dose (see below), with her other BP meds held.
#Hypertension: as above
___: Cr elevated to 1.6 from baseline of ___ returned to
baseline after IVFs.
#Concern for UTI: initially treated with CTX given equivocal UA
and hypotension. Urine culture negative, pt afebrile without
leukocytosis, and CTX was dc'd after 48 hours.
#Hypothyroidism: continued synthroid
#Hyperlipidemia: Continued pravastatin 40 mg
#Anxiety: continued paroxetine 20 mg tablet
TRANSITIONAL ISSUES
====================
-Med changes: dc'd lisinopril 40, HCTZ 25, terazosin 5 QHS.
Reduced carvedilol from 12.5 BID to 3.125 BID
[ ] follow up with PCP ___ ___. Adjust BP meds PRN
[ ] follow up postural tachycardia, monitor for any association
with symptoms or beta blockade
[ ] consider outpatient Holter monitor for syncope. cardiac
workup negative this admission (tele, TTE, stress test)
#CODE: Full (presumed)
___
Relationship: cousin
Phone number: ___
=========
___ than 30 minutes was spent on discharge planning and
coordination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / minoxidil / Percocet / metoprolol / Tylenol #3
Attending: ___.
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with HTN, asthma, OSA (not
on CPAP), DM, spinal stenosis s/p L2-L5 decompression and L3-5
fusion (___), recent admission ___ for
I&D/removal of hardware/VAC placement for a lumbar abscess
(___), as well as removal of posterior instrumentation,
laminectomy L3-4, revision arthrodesis L3-L5, lumbar wound
incision and drainage with paraspinous muscle flaps and local
tissue rearrangement (___), discharged to rehab on ___ with
prolonged course of ceftriaxone/vancomycin, who was brought back
to care from rehab with persistent back and leg pain limiting
her ambulation.
She reports that the pain has failed to improve significantly
since going to rehab, and that it has impaired her ability to do
any activity. She had initially reported weakness of her legs,
noting that it was difficult to sit up at the side of the bed,
although she subsequently clarified that this difficulty was in
fact secondary to pain. She notes that the pain is worst in the
midline of the lumbar spine, she also reports that it sometimes
goes down to her legs, where she has crampy spasm-like pain. She
describes the pain as shooting when she moves around, but notes
that there is a tightness all the time. She denied sensory
changes, incontinence, or fevers.
In the emergency room she was afebrile, with heart rates
___, BP is 150s-180s/60s-90s, satting well on room air. She
had an unremarkable BMP. Imaging was unrevealing. She was seen
by orthopedic surgery, who felt there was no appreciable change
in her exam, that the incision was well-appearing, and that the
films showed no malalignment. She received Dilaudid, insulin,
vancomycin, clonazepam, Reglan, cyclobenzaprine, fluoxetine,
amlodipine, losartan, omeprazole. She was ultimately admitted
due to poor pain control and concern that she would continue to
be unable to participate in rehab.
Of note, we reviewed her medication list from rehab, and she
reports that they were giving her several medications she
prefers not to take, including gabapentin which she felt caused
depression, Prozac, which she felt caused shakiness, Zofran
which she claims was switched to Compazine, and labetalol which
she feels is new and unnecessary.
Past Medical History:
HTN, HLD, asthma, OSA (not on CPAP), T2DM, GERD
Social History:
___
Family History:
Sister with diabetes
Physical Exam:
Admission Exam:
Vital signs:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
slightly dry MMs
CV: Heart regular, no murmur
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. Soft nontender hernia in RLQ
GU: No suprapubic tenderness
MSK: No swollen or erythematous joints; active flexion of
bilateral hips limited by pain
SKIN: back incision with sutures in place, no active discharge
or
significant erythema
EXTR: wwp, minimal edema, distal pulses intact, RUE PICC
dressing
intact
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, sensation to light touch and motor function
grossly intact/symmetric except that bilateral hip flexion
limited by pain
PSYCH: pleasant, appropriate affect
Discharge Exam:
98.0 PO 157 / 69 93 18 99 RA
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: obese, soft, non-tender, active bowel sounds
MSK: Neck supple, moves all extremities. No knee effusions or
other swelling noted.
SKIN: Surgical incision on back covered by bandage, clean / dry/
intact
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout.
PSYCH: very anxious
Pertinent Results:
ADMISSION LABS:
===============
___ 04:01PM BLOOD Glucose-97 UreaN-14 Creat-1.0 Na-140
K-4.3 Cl-100 HCO3-23 AnGap-17
___ 05:00PM URINE Color-Straw Appear-CLEAR Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.5
Leuks-SM*
___ 05:00PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-1
TransE-<1
___ 05:00PM URINE Mucous-RARE*
INTERIM LABS:
=============
___ 10:16AM BLOOD CK(CPK)-32
___ 10:16AM BLOOD Calcium-9.8 Phos-4.4 Mg-1.7
___ 10:16AM BLOOD CRP-50.0*, ESR 48
DISCHARGE LABS:
=================
___ 05:50AM BLOOD WBC-6.6 RBC-3.72* Hgb-9.7* Hct-31.7*
MCV-85 MCH-26.1 MCHC-30.6* RDW-16.7* RDWSD-51.9* Plt ___
___ 05:50AM BLOOD Glucose-186* UreaN-11 Creat-1.1 Na-138
K-4.5 Cl-99 HCO3-24 AnGap-15
___ 05:50AM BLOOD ALT-6 AST-12 AlkPhos-71 TotBili-<0.2
___ 05:50AM BLOOD Calcium-9.7 Phos-4.7* Mg-1.9 Iron-47
___ 05:50AM BLOOD calTIBC-203* Ferritn-107 TRF-156*
___ 05:50AM BLOOD CRP-12.1*
MICROBIOLOGY:
==============
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
CXR ___
Right PICC tip not clearly visualized however the line is seen
to at least the level of the right brachiocephalic vein.
LUMBOSACRAL XR ___
Postoperative changes with interval removal of the posterior
fixation hardware spanning L3 through L5. Superior endplate of
L5 is not clearly delineated on this exam, potentially related
to demineralization in the region of prior hardware placement.
If persistent clinical concern for other destructive process
such as infection, consider cross-sectional imaging by CT or
MRI.
CXR ___
There is no focal consolidation, pleural effusion or
pneumothorax identified. The size of the cardiomediastinal
silhouette is within normal limits. The tip of the right PICC
projects over the confluence of the right brachiocephalic vein
and SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 5 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. Cyclobenzaprine 10 mg PO TID:PRN pain/spasm
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID wheeze
7. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
8. Losartan Potassium 100 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. Vitamin D ___ UNIT PO DAILY
13. Bisacodyl 10 mg PO DAILY
14. CefTRIAXone 2 gm IV Q24H
15. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 17.2 mg PO QHS
18. Vancomycin 500 mg IV Q 12H
19. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
20. Fleet Enema (Saline) ___AILY:PRN constipation
21. Labetalol 200 mg PO BID
22. MetFORMIN (Glucophage) 500 mg PO TID
23. Multivitamins 1 TAB PO DAILY
24. Gabapentin 200 mg PO QID
25. nystatin 100,000 unit/gram topical DAILY
26. FLUoxetine 20 mg PO DAILY
27. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Calcium Carbonate 1000 mg PO TID:PRN indigestion
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Miconazole Powder 2% 1 Appl TP QHS
5. Pregabalin 25 mg PO DAILY
RX *pregabalin [Lyrica] 25 mg 1 capsule(s) by mouth at night
Disp #*10 Capsule Refills:*0
6. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - First
Line
7. Acetaminophen 1000 mg PO Q8H
8. amLODIPine 10 mg PO DAILY
9. Labetalol 100 mg PO BID
10. Bisacodyl 10 mg PO DAILY
11. CefTRIAXone 2 gm IV Q24H
12. ClonazePAM 0.5 mg PO TID:PRN anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day PRN
Disp #*5 Tablet Refills:*0
13. Cyclobenzaprine 10 mg PO TID:PRN pain/spasm
14. Docusate Sodium 100 mg PO BID
15. Fluticasone Propionate 110mcg 2 PUFF IH BID wheeze
16. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 4 mg 1 tablet(s) by mouth Q4H:PRN Disp #*15
Tablet Refills:*0
17. Losartan Potassium 100 mg PO DAILY
18. MetFORMIN (Glucophage) 500 mg PO TID
19. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
20. Multivitamins 1 TAB PO DAILY
21. Omeprazole 20 mg PO DAILY
22. Polyethylene Glycol 17 g PO DAILY
23. Senna 17.2 mg PO QHS
24. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
25. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
26. Vancomycin 500 mg IV Q 12H
27. Vitamin D ___ UNIT PO DAILY
28. HELD- Culturelle (Lactobacillus rhamnosus GG) 10 billion
cell oral DAILY This medication was held. Do not restart
Culturelle until speaking with infectious disease
29. HELD- FLUoxetine 20 mg PO DAILY This medication was held.
Do not restart FLUoxetine until speaking with your primary care
doctor
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
acute on chronic back pain
leg pain consistent with neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with s/p back surgery with back pain // ?post operative
complication
TECHNIQUE: AP and lateral views of the lumbosacral spine.
COMPARISON: Lumbosacral spine films from ___.
FINDINGS:
L2 through L5 laminectomy changes are again noted. Previously seen posterior
fixation hardware spanning L3 through L5 is no longer visualized. Lumbar
vertebral bodies are maintained in height and they are preserved in alignment
throughout. Of note, the superior endplate of L5 is not clearly delineated,
noting that the pedicle screws were seen in this vicinity on prior plain film.
Soft tissues are unremarkable.
Degenerative changes noted at the hips. Surgical clips project over the upper
abdomen.
IMPRESSION:
Postoperative changes with interval removal of the posterior fixation hardware
spanning L3 through L5. Superior endplate of L5 is not clearly delineated on
this exam, potentially related to demineralization in the region of prior
hardware placement. If persistent clinical concern for other destructive
process such as infection, consider cross-sectional imaging by CT or MRI.
Radiology Report
INDICATION: ___ with picc line // picc line placement eval?
TECHNIQUE: AP supine and oblique views of the chest.
COMPARISON: None.
FINDINGS:
Lungs are clear. Cardiomediastinal silhouette is within normal limits.
Right-sided PICC is identified though the tip is not clearly delineated. The
line is seen to at least the right brachiocephalic vein.
IMPRESSION:
Right PICC tip not clearly visualized however the line is seen to at least the
level of the right brachiocephalic vein.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PICC line repositioned // PICC line
placement?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC projects over the confluence of the brachiocephalic
vein and SVC. There is no focal consolidation, pleural effusion or
pneumothorax identified. The size of the cardiomediastinal silhouette is
within normal limits. The bony thorax is grossly intact.
IMPRESSION:
The tip of the right PICC projects over the confluence of the right
brachiocephalic vein and SVC, unchanged.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc replaced, unclear position, may have
been pulled out of place // confirm picc placement Contact name: ___,
___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiomediastinal silhouette is within normal limits. The tip
of the right PICC projects over the confluence of the right brachiocephalic
vein and SVC.
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Weakness
temperature: 98.4
heartrate: 84.0
resprate: 16.0
o2sat: 94.0
sbp: 155.0
dbp: 86.0
level of pain: 6
level of acuity: 3.0 | ___ is a ___ year old woman with HTN, asthma, OSA (not
on CPAP), DM, spinal stenosis s/p L2-L5 decompression and L3-5
fusion (___), recent admission ___ for
I&D/removal of hardware/VAC placement for a lumbar abscess
(___), as well as removal of posterior instrumentation,
laminectomy L3-4, revision arthrodesis L3-L5, lumbar wound
incision and drainage with paraspinous muscle flaps and local
tissue rearrangement (___), discharged to rehab on ___ with
prolonged course of ceftriaxone/vancomycin, who was brought back
to care from rehab with persistent back and leg pain limiting
her ambulation. She was admitted for pain control and while
admitted it was observed that she also had significant anxiety
limiting her recovery.
#Postoperative pain following lumbar spine surgeries
Patient underwent surgical procedures noted above on ___ and
___, discharged to rehab with prolonged IV antibiotic course,
but limited in her participation in rehab due to ongoing pain.
No concerning neurologic findings, suspected to be chronic and
postoperative pain. Continued preadmission Dilaudid with bowel
regimen, Tylenol was made standing, Flexeril PRN. She requested
to stop taking Gabapentin (said it made her more depressed),
changed to Lyrica 25 mg daily. Attempted to uptitrate to 75 mg
but she felt woozy, reduced back to 25 mg with plan to increase
slowly to 50 mg starting ___.
#Leg pain (diffuse)
#R thigh muscle strain
Complained of feeling her legs are hot at night (which she
described as her neuropathy), plus leg pain when she moves
around to sit at the edge of the bed, stand up, or walk. This is
the pain that seemed to bring her to the hopsital,
however she is unable to describe the quality of it. It is all
over her legs diffusely. Difficult to discern if both of the
types of pain she is experiencing are from neuropathy or not.
The hot sensation at night may be. Her pain with sitting at the
edge of the bed seems like it could be multifactorial. She was
overall very reluctant to move because of the pain, limiting
participation with ___ and nursing. Discussed with her and
husband that she needs to partner with nurses and staff to
maintain mobility. For R thigh pain, lidocaine patch and hot
packs were effective. She initially had R posterior knee pain
that seemed to improve without intervention. ID had recommended
U/s to r/o ___ cyst but this was unnecessary due to
resolution of pain. Iron studies not consistent with ___ as a
cause of leg pain.
#Lumbar spine osteomyelitis and abscess
Patient underwent surgical procedures noted above on ___ and
___, discharged to rehab with prolonged IV antibiotic course.
Ortho spine was consulted in ED and felt her exam was stable
without concerning neurologic findings, presumed pain and
imaging changes from significant instrumentation. She continued
Vancomycin and Ceftriaxone. ID team saw her given she was going
to miss her outpatient appointment and also agreed that her exam
was reassuring and no further imaging was necessary. Recommended
continuing weekly OPAT labs and followup in clinic. Vancomycin
dosing changed to 750 mg Q24H based on trough ___. Next OPAT
labs ___. Expected EOT ___. Continued wound care
recommendations per plastic surgery. Ideally patient will not
lay directly on her spine at rehab but this was an issues in the
hospital. Continue to encourage offloading the spine, WBAT, no
braces/splints, no bending/twisting/lifting.
#Difficult historian
Patient has been inconsistent in reporting symptoms. Seems to
have a hard time articulating what is bothering her exactly. She
also seemed to display behavior
that incongruent with her complaints (e.g., reporting
uncontrolled pain but rolling and moving easily in bed).
Endorsed feeling loopy from numerous medications, would attempt
to wean opioids ASAP in case this is contributing.
#Hypertension
Poorly controlled. She has been on losartan and amlodipine, and
was also recently started on labetalol. She requested to stop
labetalol since she feels she has been started on too many new
medications, then accepted resuming at lower dose. Increased
amlodipine from 5 to 10 mg daily, continued losartan.
#Anxiety, depression
Continued 0.5 mg 3 times daily as needed clonazepam, Held Prozac
per patient request (made her shaky reportedly). SW was
consulted to assist with coping.
#Asthma
Continued fluticasone
#GERD
Continued omeprazole 20 mg daily
#Nausea
Switched from Zofran to Compazine, added TUMS PRN
#Type 2 diabetes
While in house, held metformin, replaced with Lantus/scheduled
Humalog/sliding scale regimen |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o man with PMHx HTN, DM2, restrictive lung disease, active
smoker, aortic insufficiency, sCHF (LVEF 20%, ___ and OSA
presenting with dyspnea. He states that since ___ of last
week he has had worsening SOB. He also endorses worsening
orthopnea. He denies medication noncompliance and dietary
indiscretion. He is still actively smoking 1 PPD. He denies
cough, fevers, chills, URI symptoms, chest pain,
lightheadedness, weakness, numbness, parasthesias. He denies
any peripheral edema. He has been constipated recently and had
some abdominal pain, but this improved with laxatives.
In the ED, initial vitals were T 98.3 HR 75 BP 123/79 TT 20 SaO2
91% on RA Pain = 0. An EKG was without ischemic changes. BNP
2200, troponin < 0.01. CBC, lytes normal. CXR with interstital
pattern. Given furosemide 40mg IV x 1 and transferred to the
floor.
Prior to transfer, vitals were T 97.9 HR 74 BP 133/87 RR 25 SaO2
95% on RA. Pain = 0.
Currently, he reports continued dyspnea which is improved
slightly with supplemental O2. He has not taken any
bronchodilators.
On review of systems, s/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. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Non-ischemic cardiomyopathy - moderate dilation of left
ventricular cavity with global LV hypokinesis (LVEF = 20%) w
prior LV thrombus;
- NSVT (___) and syncope s/p single-chamber ICD ___
Virtuoso)
- Hypertension.
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation
- Restrictive lung disease (PFT ___
- AAA repair in ___ with 18 mm tube graft
- Peripheral vascular disease
- Mild CKD creat 1.2-1.3.
- Hiatal hernia.
- Esophageal dysmotility/dysphagia.
- Depression.
- s/p cataract removal.
Social History:
___
Family History:
- Father had high cholesterol and Heart disease and died at the
age of ___
- Mother died from heart disease
- Brother also died of heart problems at young age
Physical Exam:
VS: T 98.3 HR 76 BP 129/80 RR 24 SaO2 95% on 2L
GENERAL: Elderly man is anxious
HEENT: EOMI, MMM
NECK: Unable to assess JVP due to obese neck. No obviously
distended. No LAD.
CARDIAC: Irregularly irregular, no m/r/g
LUNGS: Diffuse wheezing. Subtle crackles heard at bases. Poor
air movement.
ABDOMEN: Obese, some tenderness in LLQ to deep palpation.
EXTREMITIES: Nonedematous.
SKIN: No rashes. Some erythema below eyelids and on dorsal
aspects of hands.
PULSES:
Right: 1+ DP
Left: 1+ DP
NEURO: A&Ox3. Moving all four extremities spontaneously.
Follows commands.
VS: T 97.5 BP 104/62 HR 71 RR 12 SaO2 95% on RA
Weight: 88.1 kg
GENERAL: Elderly man is anxious
HEENT: EOMI, MMM
NECK: Unable to assess JVP due to obese neck. No obviously
distended. No LAD.
CARDIAC: Irregularly irregular, no m/r/g
LUNGS: Diffuse wheezing. Subtle crackles heard at bases. Poor
air movement.
ABDOMEN: Obese, nontender, nondistended
EXTREMITIES: Nonedematous.
SKIN: No rashes. Some erythema below eyelids and on dorsal
aspects of hands.
PULSES
Right: 1+ DP
Left: 1+ DP
NEURO: A&Ox3. Moving all four extremities spontaneously.
Follows commands.
Pertinent Results:
___ 12:00PM BLOOD WBC-10.0 RBC-4.77 Hgb-12.9* Hct-38.8*
MCV-81*# MCH-27.0 MCHC-33.2 RDW-15.8* Plt ___
___ 11:15AM BLOOD WBC-8.2 RBC-5.11 Hgb-13.6* Hct-42.4
MCV-83 MCH-26.6* MCHC-32.0 RDW-15.8* Plt ___
___ 06:15AM BLOOD WBC-14.7*# RBC-5.30 Hgb-13.9* Hct-43.9
MCV-83 MCH-26.3* MCHC-31.8 RDW-15.7* Plt ___
___ 12:00PM BLOOD ___ PTT-43.1* ___
___ 12:00PM BLOOD Glucose-159* UreaN-23* Creat-1.4* Na-138
K-4.4 Cl-99 HCO3-28 AnGap-15
___ 11:15AM BLOOD Glucose-308* UreaN-24* Creat-1.5* Na-136
K-4.2 Cl-95* HCO3-28 AnGap-17
___ 06:15AM BLOOD Glucose-226* UreaN-36* Creat-1.6* Na-140
K-4.5 Cl-95* HCO3-29 AnGap-21*
___ 12:00PM BLOOD proBNP-___*
___ 12:00PM BLOOD cTropnT-<0.01
___ 08:55PM BLOOD cTropnT-0.01
CXR ___
FINDINGS: Single lead left-sided AICD is again seen with leads
in the
expected position of the right ventricle. The cardiac and
mediastinal
silhouettes are stable. Again, there is mild prominence of the
interstitial
markings which may be due to mild edema. No focal
consolidation, large
pleural effusion, or evidence of pneumothorax is seen.
IMPRESSION: Mild interstitial edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6 mg PO DAILY16
2. GlipiZIDE 10 mg PO BID
3. Vitamin D 800 UNIT PO DAILY
4. Metoprolol Succinate XL 37.5 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. Spironolactone 12.5 mg PO DAILY
7. Mirtazapine 15 mg PO HS
8. Calcium Carbonate 500 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral QD
11. Vitamin E 400 UNIT PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Aspirin EC 325 mg PO DAILY
14. Amiodarone 200 mg PO DAILY
15. HumaLOG Mix ___ KwikPen *NF* (insulin lispro protam &
lispro) 56 U Subcutaneous QAM
16. HumaLOG Mix ___ KwikPen *NF* (insulin lispro protam &
lispro) 30 U Subcutaneous QPM
17. Atorvastatin 10 mg PO DAILY
18. Imipramine 25 mg PO HS
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin EC 325 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Imipramine 25 mg PO HS
7. Metoprolol Succinate XL 37.5 mg PO DAILY
8. Mirtazapine 15 mg PO HS
9. Pantoprazole 40 mg PO Q24H
10. Spironolactone 12.5 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
13. Vitamin D 800 UNIT PO DAILY
14. Vitamin E 400 UNIT PO DAILY
15. Warfarin 4 mg PO DAILY16
Please RESUME your normal 6mg dose when you complete your course
of antibiotics (azithromycin)
RX *warfarin 4 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
16. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
17. HumaLOG Mix ___ KwikPen *NF* (insulin lispro protam &
lispro) 56 U Subcutaneous QAM
18. HumaLOG Mix ___ KwikPen *NF* (insulin lispro protam &
lispro) 30 U Subcutaneous QPM
19. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral QD
20. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Apply one patch once a day Disp #*14
Unit Refills:*0
21. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute decompensated systolic heart failure (LVEF 20%)
Non-ischemic cardiomyopathy
Coronary artery disease
Diabetes mellitus
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: CHF, hypertension, HLD, presenting with dyspnea.
___.
FINDINGS: Single lead left-sided AICD is again seen with leads in the
expected position of the right ventricle. The cardiac and mediastinal
silhouettes are stable. Again, there is mild prominence of the interstitial
markings which may be due to mild edema. No focal consolidation, large
pleural effusion, or evidence of pneumothorax is seen.
IMPRESSION: Mild interstitial edema.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 98.3
heartrate: 75.0
resprate: 20.0
o2sat: 91.0
sbp: 123.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ M with HTN, DM2, AR, sCHF (LVEF 20%) and OSA, history of VT,
cardiac arrest s/p ICD presenting with dyspnea.
Mr. ___ dyspnea was thought to be multifactorial, with
contributions from acutely decomensated heart failure,
exacerbation of COPD, superimposed on an already poor underlying
pulmonary substrate of restrictive lung disease (perhaps related
to amiodarone), obstructive sleep apnea, and obesity
hypoventilation syndrome. His exam was significant for wheezing
and the absence of pronounced wet crackles. He had elevated JVP
but was without peripheral edema. Nevertheless, his BNP was
elevated and his recent device clinic note documented an
elevated OptiVute fluid index, suggesting pulmonary edema.
Thus, he likely had acute decomensated systolic heart failre and
an exacerbation of COPD. His PFTs from ___ suggested a
predominantly restrictive defect, but his exam with wheezing,
active smoking, and response to bronchodilators were consistent
with COPD.
He was given bronchodilators, a short course of prednisone and
azithromycin and was diuresed to a weight of 89.1 kg upon
discharge with an increased dose of home diuretic. The patient
does not currently own a scale at home but was instructed to
purchase one.
We also strongly encouraged smoking cessation (patient still
smoking 1 pack per day) and provided education as well as a
course of nicotine replacement therapy.
#) DIABETES MELLITUS, TYPE 2: Continued on home glipizide, NPH,
and HISS.
- Mildly hyperglycemic while on short course of prednisone, but
no changes in regimen made since this was a temporary
intervention.
#) ATRIAL FIBRILLATION: Rate well controlled while in house.
Continued metoprolol. We dose-reduced his warfarin given
concurrent antibiotic therapy for the duration of his
antibiotics.
#CODE: Full code (confirmed)
#CONTACT: Patient, ___ (Ex-wife/HCP) ___
TRANSITIONAL ISSUES
===================
[ ] Patient should be on an ___ if he can tolerate
this due to his severe heart failure and diabetes.
[ ] Consider enrolling the patient in heart failure home
monitoring program to monitor weight, medication adherence.
[ ] Consider repeat PFTs to evaluate for progression of
restrictive lung disease and possible emergence of obstructive
disease
[ ] Please check a serum chemistry at the next appointment since
we increased his diuretic dose |