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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
loss of consciousness, headache
Major Surgical or Invasive Procedure:
___ Bedside Lumbar Puncture
History of Present Illness:
___ is a ___ right-handed woman who was in
the
neurology clinic having a lumbar puncture performed for a
history
of pseudotumor cerebri (opening pressure 35 cm in early ___
who
had a vasovagal syncopal event and was sent to the ED. She
states
that she has been having increasing severity to her headaches
over the past several months and is now on both topiramate as
well as Diamox. Her only relief has come after a large volume
tap
and then the head pain returns within ___ days. She feels that
she has lost some peripheral vision over the past few months as
well. Her headaches are often worst in the morning, but are
consistent in quality throughout the day with no positional
component. No nausea/emesis. In the clinic today she remembers
the needle going in, but then cannot remember anything after
that
event until she awoke in the ED. She has some point tenderness
at
the site, but otherwise her major complaint is the headache. The
note from Dr. ___ that her opening pressure was 35 then
dropped to 20 as she lost consciousness.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
History of pseudotumor cerebri
Mitral Valve prolapse
4 C sections
Wrist Surgery
- prior w/u for pituitary mass (no malignancy)
Social History:
___
Family History:
Father - cancer
5 children ages ___
Physical Exam:
ADMISSION
Vitals: 98.4 63 108/68 18 100%
General: Awake, cooperative, in pain with eyes clenched.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Spine: pain along lower back at LP site, no bulge, no hematoma
palpable from surface
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. VFF to confrontation. Funduscopic
exam limited given small pupils after narcotic administration.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 10:45AM BLOOD WBC-7.3 RBC-4.76 Hgb-13.0 Hct-42.2 MCV-89
MCH-27.3 MCHC-30.9* RDW-14.1 Plt ___
___ 06:40AM BLOOD WBC-4.5 RBC-3.86* Hgb-11.0* Hct-34.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.3 Plt ___
___ 10:45AM BLOOD Neuts-64.6 ___ Monos-5.6 Eos-3.6
Baso-0.6
___ 08:00PM BLOOD Neuts-66.9 ___ Monos-5.2 Eos-3.8
Baso-0.4
___ 08:00PM BLOOD ___ PTT-30.7 ___
___ 10:45AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-89 UreaN-11 Creat-1.1 Na-140
K-3.8 Cl-109* HCO3-25 AnGap-10
___ 10:45AM BLOOD ALT-18 AST-27 AlkPhos-97 TotBili-0.3
___ 10:45AM BLOOD Calcium-9.8 Phos-3.6 Mg-2.2
___ 06:40AM BLOOD TSH-0.53
___ 10:45AM BLOOD HCG-<5
UA negative
CXR negative
Urine Culture NGTD
Blood Cultures NGTD x 2
CSF Hematology
ANALYSIS WBC RBC Polys Lymphs Monos Macroph
___ 14:12 11 0 02 40 5 55
CSF gram stain no microorganisms or leukocytes
CSF culture NGTD
___ 10:33 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Reported to and read back by ___ ON ___
@ 12:14PM.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Medications on Admission:
acetazolamide 500 mg BID
topiramate 75 BID
citalopram 40 mg daily
clonazepam 1 mg TID
Doxepin 25 mg ___ tabs at night
omeprazole 20 mg daily
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q12H
2. Citalopram 40 mg PO DAILY
3. Clonazepam 1 mg PO TID
4. Doxepin HCl 25 mg PO HS
5. Omeprazole 40 mg PO DAILY
6. Topiramate (Topamax) 75 mg PO BID
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS: Syncope, Headache, Bronchitis, Influenza
SECONDARY DIAGNOSIS: Idiopathic intracranial hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Peripheral constriction of the visual fields
bilaterally and widening of the physiologic blind spot in both
eyes.
Followup Instructions:
___
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Fever and cough.
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of pneumonia.
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Fever.
Cardiomediastinal contours are normal. The lungs are clear. There is no
evidence of pneumonia or pleural effusion.
Radiology Report
INDICATION: ___ year old woman with IIH s/p two recent LPs, syncope during
first LP, here with fever/cough from likely bronchitis but just found on the
floor, doesn't know how she fell, mildly confused. Assess for head trauma,
SDH, contusion.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal, sagittal and thin
slice bone images were reviewed.
COMPARISON: NECT of the head on ___
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. Prominent ventricles and sulci suggest atrophy noteworthy for the
patient's age. The basal cisterns appear patent and there is preservation of
gray-white differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. No facial or cranial soft tissue
abnormalities are present.
IMPRESSION: No evidence of acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, HEADACHE
temperature: 98.4
heartrate: 63.0
resprate: 18.0
o2sat: 100.0
sbp: 108.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | ___ yo RHW with IIH refractory to acetazolamide and topiramate
who had an episode of syncope during an outpatient lumbar
puncture. The syncope was most likely vasovagal in the setting
of pain during the procedure. Given the refractory nature of her
IIH to medications, she may benefit from evaluation for VPS
placement. She was treated for her headache with ketorolac ___
mg q6h, tramadol 50 mg q6h prn, and acetaminophen 650 mg q6h
prn. She received ondansetron for nausea. She had a bedside
lumbar puncture performed on ___ with 30 cc removed to help
alleviate her headache (with additional fluid given to Dr. ___
___ for a research protocol). Neurosurgery was consulted for
formal evaluation for placement of a ventriculoperitoneal shunt.
Formal visual field testing was scheduled with
Neuro-Ophthalmology. She did have a fever overnight on ___
with cultures and CXR obtained, all of which were negative. She
was thought to have a bronchitis for which she was treated with
five days of Azithromycin. She had a second fever overnight on
___ to 105, was placed on APAP and a cooling blanket with
resolution of fever, and was started on empiric treatment for
possible hospital-associated pneumonia; she was initially
thought to possibly have meningismus, but she had been sleeping
in a fetal position and just felt sore; she had no other signs
suggesting meningitis. Her repeat CXR and cultures were again
negative. A flu swab was obtained which revealed that she has
Influenza A. She was placed under droplet precautions/isolation.
She did finally get her formal visual field testing with
ophthalmology and evaluation by neuro-ophthalmology. She was
evaluated by ___ and was felt to not be stable on her feet, so
she was discharged to rehab to return at a later time to the
___ clinic for evaluation for VPS.
.
PENDING STUDIES: none
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
scrotal pain, swelling
Major Surgical or Invasive Procedure:
NONE at ___ during this admission
s/p outpatient vasectomy ___
History of Present Illness:
Patient is a ___ male who had a vasectomy yesterday afternoon at
___. Procedure was uncomplicated but over the
evening he developed worsening scrotal swelling and bruising. He
presented to ___ overnight where he had a scrotal
ultrasound that was equivocal for testicular blood flow on the
left. He was transferred to ___ where scrotal ultrasound was
normal with good flow bilaterally. He had significant bruising
and swelling with large hematoma. Pain was controlled with
narcotics. He denies fevers, chills, nausea, emesis, dysuria,
hematuria or difficulty voiding.
Past Medical History:
ADD
s/p Septum repair
depression/anxiety
Social History:
___
Family History:
Father with prostate cancer
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Hemiscrotum Incision c/d/i w/out evidence infection, marked
ecchymosis at penile shaft/scrotum noted but with with resolving
induration
Ecchymosis is spreading to dependent buttocks, thigh, abdomen.
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 04:38AM BLOOD WBC-9.3 RBC-4.28* Hgb-12.4* Hct-37.1*
MCV-87 MCH-29.0 MCHC-33.4 RDW-12.0 RDWSD-38.1 Plt ___
___ 04:38AM BLOOD Neuts-82.2* Lymphs-10.7* Monos-6.4
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.60* AbsLymp-0.99*
AbsMono-0.59 AbsEos-0.02* AbsBaso-0.02
___ 04:38AM BLOOD ___ PTT-30.0 ___
___ 04:38AM BLOOD Glucose-130* UreaN-12 Creat-1.0 Na-136
K-4.1 Cl-99 HCO3-27 AnGap-14
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Adderall
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hrs Disp #*40 Tablet
Refills:*0
3. 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
4. Acetaminophen 1000 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
hematoma, scrotal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SCROTAL U.S.
INDICATION: ___ male with scrotal hematoma status post vasectomy. No
Doppler was noted in the left testicle on bedside ultrasound. Evaluate for
testicular ischemia.
TECHNIQUE: Greyscale with color and spectral Doppler ultrasound of the
scrotum was performed with a linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 5.1 x 2.7 x 1.9 cm.
The left testicle measures: 4.3 x 2.9 x 2.9 cm.
The testicular echogenicity is normal, without focal abnormalities. Both
arterial and venous waveforms are noted in the bilateral testicles.
The epididymis is normal bilaterally.
There is a large hematoma along the left scrotum spanning approximately 11.7
cm. A moderate-sized left hydrocele is also noted.
IMPRESSION:
1. Normal arterial and venous waveforms noted in the bilateral testicles.
2. Large left scrotal hematoma and moderate hydrocele.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Testicular pain
Diagnosed with Postproc hemor of a GU sys org following a GU sys procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 98.6
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 103.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ his patient was admitted to Dr. ___
service with an enlarged ecchymotic scrotum after outpatient
vasectomy on ___, 24hours prior. He denied fever, hematuria,
dysuria but endorsed marked swelling, ecchymosis, concern and
pain. He was ambulatory and able to void; admitted for serial
exams, pain control. At discharge on hospital day three, Mr.
___ pain was well controlled with oral pain medications,
he was tolerating regular diet, ambulating without assistance,
and voiding without difficulty. Ecchymosis and edema were
resolving. Incision at discharge without erythema or evidence
of dehiscence. He will follow-up with his urologist as directed
in about one week time. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nortriptyline / Ultram /
Diltiazem / Ace Inhibitors / Norvasc / Percocet / Zetia /
Cymbalta / Doxycycline / Minocycline / ciprofloxacin /
simvastatin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with AAA, Afib on coumadin, complete heart block s/p PPM,
chronic diastolic heart failure who presents with subacute
shortness of breath. Patient reports 6 weeks of progressively
worsening shortness of breath with associated PND and orthopnea.
Denies chest pain, changes in weight ___ edema. Endorses acute
worsening of symptoms over last few days. Was recent treated for
sinusitis with antibiotics and in the setting of this, was told
to stop daily furosemide. Denies cough, fevers, or chills. Has
progressive DOE. No nausea, vomiting, or changes in bowel
habits. Was seen by PCP office today who suggested that she come
to the ED for evaluation.
In ED, work-up was notable BNP of 11000, normal CBC and INR. CXR
was notable for cardiomegaly and vascular congestion. She was
given nebulizers and steroids for ?COPD and was then admitted
for further evaluation.
On arrival the floor, patient reports mild improvement in
symptoms. Incidentally also complains of posterior left sided
back pain in mid back. Denies recent falls or trauma. Patient
notably dyspneic on movement.
ROS: A 10 point ROS was completed and otherwise negative.
Past Medical History:
PMH: AAA s/p rupture, Afib, bronchiectasis, carotid stenosis (R
60-69%, L 40-59%), chronic back pain, COPD, CHF, gastritis,
GERD,
hyperlipidemia, HTN, mesenteric ischemia, osteoarthritis,
osteoporosis, peripheral neuropathy, peripheral vascular
disease,
b/l renal artery stenosis, AV block, spinal stenosis, SVT,
recurrent UTIs, L iliac pseudoaneurysm, PMR, skin cancer
PSH: R SFA-peroneal bypass (___), EVAR (___), open AAA repair
(rupture, ___, L renal stent (___), angio/celiac & SMA stents
___ hypogastric coil embolization w/ extension of stent
graft (R iliac pseudoaneurysm, ___, L4-5 dcompressive
laminectomies/medial facetectmies/foraminotomies & L5-S1
posterior lumbosacral fusion, b/l cataract extraction,
endometrial curettage, hiatal hernia repair, open
cholecystectomy
Social History:
___
Family History:
No history of lung disease
Physical Exam:
ADMISSION EXAM:
VS: 97.5 148/74 60 20 99%RA
Gen: elderly appearing female, mildly dyspneic on movement, NAD
HEENT: EOMI, PERRL, MMM
Neck: supple, JVP 2-3cm above clavicle
Pulm: crackles at posterior bases
CV: nl s1s2 RRR no murmurs
Back: focal TTP over left posterior rib without overlying skin
changes or ecchymosis
Abd: soft, NT ND +BS
Ext: no edema, wwp
Neuro: grossly intact
DISCHARGE EXAM:
Vital Signs: 98.1 150/66 56 18 98%RA
Pain ___
Wt 112.7 kg
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, ___ systolic murmur loudest at the LUSB
PULM: very scant bibasilar rales
GI: S/NT/ND, BS present
EXT: no significant ___ edema, no calf tenderness
NEURO: Non-focal
Pertinent Results:
Admission Labs:
___ 01:45PM BLOOD WBC-8.1 RBC-3.52* Hgb-10.8* Hct-34.5
MCV-98 MCH-30.7 MCHC-31.3* RDW-14.1 RDWSD-50.6* Plt ___
___ 01:45PM BLOOD Neuts-73.5* Lymphs-10.8* Monos-7.7
Eos-5.9 Baso-1.1* Im ___ AbsNeut-5.95# AbsLymp-0.87*
AbsMono-0.62 AbsEos-0.48 AbsBaso-0.09*
___ 01:45PM BLOOD ___ PTT-32.7 ___
___ 01:45PM BLOOD Glucose-103* UreaN-28* Creat-1.3* Na-144
K-5.2* Cl-108 HCO3-22 AnGap-19
___ 01:45PM BLOOD ___
___ 07:30AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
Discharge Labs:
___ 07:32AM BLOOD WBC-6.6 RBC-3.45* Hgb-10.6* Hct-33.2*
MCV-96 MCH-30.7 MCHC-31.9* RDW-13.9 RDWSD-48.7* Plt ___
___ 10:30AM BLOOD ___ PTT-37.0* ___
___ 07:32AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-140
K-4.5 Cl-107 HCO3-24 AnGap-14
___ 07:32AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:30PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
Blood Culture, Routine (Final ___: NO GROWTH.
ECG - Atrial flutter and ventricular paced rhythm with capture,
similar to that
recorded on ___ without diagnostic interim change
CXR - FINDINGS:
The heart continues to be enlarged with mild pulmonary vascular
congestion.
Increased AP diameter of the chest reflects COPD. No focal
consolidation,
pleural effusion or pneumothorax is seen. A left-sided cardiac
pacing device
has its leads over the right atrium and ventricle. Prominence
of the
pulmonary artery is noted, reflecting pulmonary hypertension.
IMPRESSION:
Cardiomegaly with mild pulmonary vascular congestion.
T Spine X-Ray:
IMPRESSION:
1. Osteopenia, sigmoid scoliosis, and mild thoracic spine
degenerative
changes.
2. Limited sensitivity for detection or fractures, but no overt
vertebral body
compression or spondylolisthesis identified.
3. Please note that most of the ribs, including most of the left
tenth rib are
not included on this study.
4. Dense aortic calcification, with the aortic arch at the upper
limits of
normal.
Rib Films: IMPRESSION:
Cardiomegaly. Left fifth rib deformity may represent a old
healed fracture.
No definite acute fracture.
TTE - The right atrium is moderately dilated. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF = 70%). There is mild (non-obstructive) focal
hypertrophy of the basal septum. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace 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 ___,
the findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Qvar (beclomethasone dipropionate) 160 mcg inhalation BID
3. Furosemide 20 mg PO DAILY
4. Gabapentin 600 mg PO QHS
5. HydrALAzine 100 mg PO Q8H
6. Isosorbide Dinitrate 30 mg PO TID
7. Metoprolol Tartrate 50 mg PO BID
8. Ranitidine 300 mg PO QHS
9. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Docusate Sodium 100 mg PO QHS
2. Furosemide 20 mg PO DAILY
3. Gabapentin 600 mg PO QHS
4. HydrALAzine 100 mg PO Q8H
5. Isosorbide Dinitrate 30 mg PO TID
6. Metoprolol Tartrate 50 mg PO BID
7. Ranitidine 300 mg PO QHS
8. Warfarin 1 mg PO ___
Your warfarin dose was decreased b/c your INR was high. Discuss
this w/ the ___ clinic on ___.
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
10. Qvar (beclomethasone dipropionate) 160 mcg inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on Chronic Diastolic Heart Failure
Atrial Fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old female with shortness of breath. Evaluate for
pneumonia versus congestive heart failure.
TECHNIQUE: AP frontal and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___ and CT from ___.
FINDINGS:
The heart continues to be enlarged with mild pulmonary vascular congestion.
Increased AP diameter of the chest reflects COPD. No focal consolidation,
pleural effusion or pneumothorax is seen. A left-sided cardiac pacing device
has its leads over the right atrium and ventricle. Prominence of the
pulmonary artery is noted, reflecting pulmonary hypertension.
IMPRESSION:
Cardiomegaly with mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old woman with afib on Coumadin and history of back
surgery with pain on left posterior 10th rib. no recent falls // evaluate for
fracture
TECHNIQUE: Two views of the thoracic spine.
COMPARISON: None.
FINDINGS:
There is pronounced diffuse osteopenia, with mild sigmoid scoliosis, convex
left in the upper thoracic and convex right in the lower thoracic spine.
There are mild background degenerative changes in the thoracic spine. No
obvious compression fracture, though subtle vertebral body height loss,
endplate scalloping, or nondisplaced fracture might not be apparent on these
views. No spondylolisthesis.
There is DENSE aortic calcification, with the aortic arch at the upper limits
of normal. Pacemaker wires partially imaged.
IMPRESSION:
1. Osteopenia, sigmoid scoliosis, and mild thoracic spine degenerative
changes.
2. Limited sensitivity for detection or fractures, but no overt vertebral body
compression or spondylolisthesis identified.
3. Please note that most of the ribs, including most of the left tenth rib are
not included on this study.
4. Dense aortic calcification, with the aortic arch at the upper limits of
normal.
Radiology Report
EXAMINATION: RIB BILAT, W/AP CHEST
INDICATION: ___ year old woman with ___ posterior rib pain // please assess
for frx
TECHNIQUE: Frontal chest radiograph. Oblique rib views.
COMPARISON: ___
FINDINGS:
The heart is moderately enlarged. No effusion or pneumothorax. No
consolidation. No evidence of pulmonary edema. There is a pacemaker in-situ.
Some contour abnormality of the left lateral fifth rib may reflect healed
fracture. Aortic arch calcification is seen. Vascular stents in the abdomen,
surgical clips the right upper quadrant, lumbar spine hardware in-situ.
IMPRESSION:
Cardiomegaly. Left fifth rib deformity may represent a old healed fracture.
No definite acute fracture.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 99.3
heartrate: 59.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | ___ with AAA, Afib on coumadin, complete heart block s/p PPM,
chronic diastolic heart failure, COPD, HTN, HLD, GERD, recurrent
UTIs, who presented of 6 weeks of worsening shortness of breath.
# Shortness of Breath / Acute on Chronic Diastolic HF: Overall
presentation likely consistent with acute on chronic dCHF in the
setting of recent holding her lasix. Pt reports that breathing
was much improved after Lasix given on admission. No wheezing on
exam to suggest COPD flare, no consolidation to suggest PNA. TTE
stable from ___. She was given a few doses of IV lasix and then
placed back on her home regimen. Breathing comfortably at the
time of discharge. She was discharged home with telehealth.
# Back Pain: With TTP noted over ___ posterior rib on
presentation. T-spine films did not capture this rib; f/u rib
films without obvious acute fracture.
# Afib: On Coumadin. INR was subtherapeutic on presentation so
Coumadin dose initially increased. However, once INR in ___
range, she was lowered back down to home dose (2 mg / day). On
the day of discharge, INR was 3.0, so coumadin dose was
decreased to 1 mg per day per pharmacy recs. She will have INR
rechecked on ___, results should be sent to ___
___ clinic.
# GERD: on home ranitidine
# HTN: on home hydral, isosorbide, metoprolol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute left leg pain
Major Surgical or Invasive Procedure:
___: L CFA cut down, L SFA and popliteal thrombectomy,
bedside fasciotomies of superficial compartments
History of Present Illness:
Mr. ___ is a ___ former smoker with h/o CAD with prior MI and
PCI/stent x2 (___), HTN/HLD gastric ulcer (c/b UGIB on
warfarin) presenting with left lower extremity pain and loss of
sensation. Patient reports that he began to experience "pins and
needles" in his left foot about 3 hours prior to arrival in the
ED. His left lower extremity paresthesias progressed to loss of
sensation, severe pain, and loss of motor function over a 3 hour
period extending up to his left knee. He denies any injury to
his left leg, history of claudication, rest pain, lower
extremity swelling, or prior vascular procedures.
On arrival to the ED, he was afebrile, tachycardic to HR 100,
hypertensive to 198/25 118, RR 22 with SpO2 of 100% on
non-rebreather. Of note, the patient did not endorse shortness
of breath, and he reported that he has not seen a healthcare
provider ___ ___ years.
ROS:
(+) per HPI
(-) Denies pain, fevers, chills, night sweats, unexplained
weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
PMH: HTN, HLD, prior MI ___ s/p PCI and stent placement x2;
gastric ulcer s/p UGIB in ___ follow warfarin initiation
PSH: right hip/femur surgery
Social History:
___
Family History:
CAD/MI, no HTN, no DM
Physical Exam:
Admission Physical Exam:
Vitals: 99 198/25 22 100%
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: bilateral rhonchi, wheezing bilaterally, tachypneic
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, no scars seen
Ext: No ___ edema, left leg is cool to the knee, pale, he is not
able to move his toes and is insensate from the toes to the
knee, no palp pulse below femoral on left
Pulses: R: p/p/p/d L: p/-/-/-
Neuro: complete loss of sensory and motor function of LLE below
knee; CNII-XII intact
Discharge Physical Exam:
Vitals:
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: bilateral rhonchi, wheezing bilaterally, tachypneic
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, no scars seen
Ext:
Pulses: R: p/p/p/d L: p/d/p/p
Neuro:
Pertinent Results:
ADMISSION LABS
==============
___ 03:50PM BLOOD WBC-20.9* RBC-5.01 Hgb-14.9 Hct-44.9
MCV-90 MCH-29.7 MCHC-33.2 RDW-12.0 RDWSD-39.5 Plt ___
___ 03:50PM BLOOD ___ PTT-150* ___
___ 05:43AM BLOOD Glucose-113* UreaN-9 Creat-0.9 Na-135
K-3.8 Cl-101 HCO3-23 AnGap-15
___ 05:43AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9
___ 03:50PM BLOOD cTropnT-<0.01
___ 03:50PM BLOOD Lipase-34
___ 03:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:02PM BLOOD Type-ART pO2-100 pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
___ 04:02PM BLOOD Hgb-15.8 calcHCT-47 O2 Sat-96 COHgb-1
MetHgb-0
CK Trend:
___ 03:50PM BLOOD CK(CPK)-66
___ 06:00AM BLOOD ___
___ 11:38AM BLOOD ___
___ 05:58PM BLOOD ___
___ 05:50AM BLOOD ___
___ 06:05AM BLOOD CK(CPK)-___*
DISCHARGE LABS
===============
IMAGING
=======
___ CXR:
Heart size is normal. Mild atherosclerotic calcifications are
noted at the aortic knob. The mediastinal and hilar contours
are normal. Pulmonary vasculature is normal. Lungs are
hyperinflated with emphysematous changes noted. Lungs are
otherwise clear without focal consolidation. No pleural
effusion or pneumothorax is identified. There are no acute
osseous abnormalities.
___ CT Chest:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Moderate to severe centrilobular emphysema.
3. Diffuse air wall thickening with mucoid impaction/secretions
within left
lower lobe bronchus and segmental bronchi compatible with
airways disease. No
pneumonia.
4. 3-mm left upper lobe pulmonary nodule. Dedicated chest CT
follow-up in ___
year is recommended.
5. Enlarged right hilar lymph node, likely reactive.
___ CTA Aorta/Bifem/Iliac Runoff:
1. Multifocal areas of occlusion involving the origin and
proximal left
superficial femoral artery as well as left proximal and mid deep
femoral
artery, both reconstituted distally by collaterals.
2. Lack of opacification of the left lower extremity arteries
from the
below-knee left popliteal artery to the foot, which is likely
due to extremely
slow flow.
3. Short segment occlusion of the right tibioperoneal trunk with
reconstitution immediately distally to allow for an otheriwise
normal
three-vessel runoff to the right foot.
4. Colonic diverticulosis.
___ TTE:
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild mitral regurgitation with normal valve
morphology. Mild pulmonary artery systolic hypertension.
OPERATIVE REPORTS
=================
___.
Signed Electronically by ___ on ___ 8:50 AM
Name: ___ ___ No: ___
Service: Date: ___
Date of Birth: ___ Sex: M
Surgeon: ___, ___
ASSISTANT: ___, MD
PREOPERATIVE DIAGNOSIS: Left lower extremity acute limb
ischemia.
POSTOPERATIVE DIAGNOSIS: Left lower extremity acute limb
ischemia.
PROCEDURES:
1. SFA, profunda, popliteal, and peroneal embolectomy.
2. Placement of sheath into the common femoral artery,
third order vessel.
3. Left lower extremity angiogram.
INDICATIONS: This is a ___ gentleman who is a
chronic smoker and has a history of hypertension and coronary
artery disease but who is noncompliant with his medical care
who presented to an outside hospital complaining of acute
onset of pain, numbness, and weakness of his left lower
extremity. He was transferred to our institution out of
concern of acute limb ischemia. CTA was performed here which
showed a short segment 3 cm SFA occlusion and no
visualization of contrast below the left popliteal artery.
The risks, benefits, and alternatives of femoral cutdown and
embolectomy were explained to the patient, specifically the
high risk of limb loss or need for fasciotomy and the patient
agreed to the procedure and signed informed consent.
DETAILS OF PROCEDURE: The patient was brought to the hybrid
room and placed on the OR table in supine position. Both
groins were prepped and draped in the usual sterile fashion.
A time-out was performed identifying the correct patient,
site of operation and procedure. Preoperative antibiotics
were given. We began by making a longitudinal incision over
the left common femoral artery which was easily palpable,
dissection was carried down, and we easily dissected out the
common femoral artery, the SFA, and the profunda. Vessel
loops were placed around each of these to gain proximal and
distal control. ___ clamp was placed on
the common femoral artery and after giving a bolus of 3000
units of heparin.
Next an arteriotomy was made in the common femoral artery just
proximal to the profunda using an 11 blade. This was extended
with Potts scissors. A ___ ___ balloon was passed down the
SFA and a good deal of thrombus was extracted. This was
repeated
until no further clot could be retrieved. The same was done
with
the profunda and again thrombus was retrieved. Next we used a
___
___ catheter and passed this down into what we believed was
the peroneal. We did not get any clot back when this was done
and
lastly we passed a ___ ___ catheter proximally into the
external iliac artery. No clot was retrieved and we observed
excellent inflow.
At this point, we partially closed the arteriotomy with ___
Prolene but before tying down the knot we inserted a sheath into
the common femoral artery and performed a left lower extremity
angiogram. This showed patent SFA, popliteal, and tibial
vessels
down into the foot. At this point, we were satisfied with the
results of the intervention and thus elected to terminate the
procedure. Therefore the ___ Prolene was tied down to close the
arteriotomy in the common femoral artery and the groin was then
closed in 3 layers with ___ Vicryl. The skin was closed with
staples and a dry sterile dressing was applied.
The patient tolerated the procedure well. There were no
immediate complications. Dr. ___ was present for all
portions of the case. The patient was then transferred to
the ___ care unit in good condition.
___.
Name: ___ ___ No: ___
Service: Date: ___
Date of Birth: ___ Sex: M
Surgeon: ___, ___
PREOPERATIVE DIAGNOSIS: Impending compartment syndrome.
POSTOPERATIVE DIAGNOSIS: Impending compartment syndrome.
PROCEDURES: Fasciotomy of anterior compartment and posterior
superficial compartment.
ASSISTANT: ___, MD, ___, MD.
ANESTHESIA: Local.
BRIEF HISTORY: This patient is a ___ man who
presented with acute left lower extremity ischemia. He was
taken to the operating room for thromboembolectomy. He
regained a pulse. Of note is that prior to his operation he
was completely insensate from the knee down and had no
appreciable motor function. He was brought to the recovery
room after his embolectomy procedure and has no improvement
in his motor function. For this reason, I felt that it would
be reasonable to perform a prophylactic fasciotomy in order
to prevent compartment syndrome. The procedure and risks
were explained to the patient. He understood and wished to
proceed.
DESCRIPTION OF PROCEDURE: The patient was awake but
insensate from the knee down. He was prepped and draped in
the usual manner using a ChloraPrep solution. After a
standard time-out was performed, the skin over the anterior
compartment was locally infiltrated with 1% lidocaine
solution. An incision was then made and taken down through
the fascia. There was some mild bulging of the muscle but
the muscle appeared healthy and viable. We next turned our
attention to the medial leg. For this we also instilled 1%
lidocaine along the tract of the incision. The incision was
then made using a knife and the fascia was opened using a
___. Again the muscle bulged mildly but it appeared
healthy and viable. The incisions were then packed with
saline moistened gauze and the leg was wrapped with Kerlix.
The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: There were no intraoperative complications
noted.
PLASTIC SURGERY
___ (BID #: ___
PREOPERATIVE DIAGNOSIS: Left lower extremity open wound
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Debridement of left lower extremity open wound with
local advancement flap closure and split thickness skin graft
from left thigh
SURGEON: ___, ___
FIRST ASSISTANT: ___
INDICATIONS: Patient is a ___ year old male with an open wound of
the left lower extremity after a fasciotomy. These were medial
and lateral fasciotomy incisions. We discussed the procedure
and
indications and the patient wishes to proceed. The risks include
bleeding, infection, abnormal scarring, difficulty healing,
graft
loss, and need for further surgery.
PROCEDURE: Patient was prepped and draped in usual sterile
fashion after general endotracheal anesthesia was administered
and preoperative antibiotics were given.
The 2 wounds on the left lower extremity were debrided and
washed
out. The medial wound was 16 x 3 cm in size while the lateral
wound was 23 x 5.5 cm. At the medial incision a local
advancement
flap was designed with wide undermining and we were able to
close
the incision. The local advancement flap was approximately 40 sq
cm. Closure was performed with ___ PDS, ___ Monocryl, and ___
Nylon sutures.
Next a split thickness skin graft was harvested from the left
thigh after 1% lidocaine with epinephrine was injected at the
thigh. This graft was meshed 1:1.5 and secured on the lower leg
with ___ chromic sutures. The skin graft was 125 sq cm. A
xeroform was placed on the donor site. A VAC dressing was placed
on a xeroform over the skin graft. A loose dressing of 4x4 and
Kerlix was placed on all sites and the patient was then
extubated
and brought to the recovery room in stable condition.
I was present for the critical portions of the case as per CMS
guidelines.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. esomeprazole magnesium 1 tablet oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute limb ischemia secondary to thromboembolism, compartment
syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ man with acute cold left foot, dyspnea, and tachypnea
; evaluate for pulmonary embolus.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 0.8 mGy (Body) DLP = 0.4
mGy-cm.
2) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 3.2 mGy (Body) DLP = 1.6
mGy-cm.
3) Spiral Acquisition 4.9 s, 38.6 cm; CTDIvol = 7.4 mGy (Body) DLP = 285.9
mGy-cm.
Total DLP (Body) = 288 mGy-cm.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
high-grade stenosis, occlusion, dissection, or aneurysmal formation. Soft
plaque involving the proximal right brachiocephalic artery results in less
than 50% narrowing. There is no evidence of penetrating atherosclerotic ulcer
or aortic arch atheroma present. The heart is normal in size. No evidence of
pericardial effusion. Coronary artery calcifications are moderate. No
significant aortic valve or mitral annulus calcifications.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental
pulmonary arteries. The main and right pulmonary arteries are normal in
caliber, and there is no evidence of right heart strain.
Enlarged right hilar lymph node measures up to 15 mm in short axis dimension,
likely reactive. No supraclavicular, axillary, mediastinal, or left hilar
lymphadenopathy. The thyroid gland appears unremarkable. No mediastinal
hematoma.
Centrilobular emphysema is moderate to severe. Bibasilar atelectasis is mild.
A left upper lobe pulmonary nodule measures 3 mm (series 3, image 51). There
is diffuse airway wall thickening with secretion/ mucous impaction within the
left lower lobe bronchi (e.g., series 3, image 160, 154, 143, 136, 128). No
focal consolidations to indicate focal pneumonia. No pleural effusions or
pneumothorax.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Sub cm sclerotic benign-appearing lesion in the left scapula is most likely a
bone island (series 3, image 135; series 602b, image 63). Multilevel
degenerative changes in the thoracic spine are extensive particularly in the
lower thoracic spine. No evidence of an acute fracture. The spinal canal is
patent.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Moderate to severe centrilobular emphysema.
3. Diffuse air wall thickening with mucoid impaction/secretions within left
lower lobe bronchus and segmental bronchi compatible with airways disease. No
pneumonia.
4. 3-mm left upper lobe pulmonary nodule. Dedicated chest CT follow-up in ___
year is recommended.
5. Enlarged right hilar lymph node, likely reactive.
RECOMMENDATION(S): Chest CT in ___ year to follow-up 3-mm left upper lobe
pulmonary nodule.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. in person on ___ at 4:36 ___, 1 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ man with a cold left foot, dyspnea, tachypnea.
Evaluate for arterial occlusion.
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 18.4 s, 145.1 cm; CTDIvol = 3.1 mGy (Body) DLP =
451.1 mGy-cm.
2) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
3) Spiral Acquisition 18.8 s, 147.9 cm; CTDIvol = 10.1 mGy (Body) DLP =
1,495.9 mGy-cm.
4) Spiral Acquisition 10.3 s, 80.6 cm; CTDIvol = 6.3 mGy (Body) DLP = 506.3
mGy-cm.
Total DLP (Body) = 2,459 mGy-cm.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
VASCULAR:
CTA Abdomen and pelvis:
The abdominal aorta is normal caliber without evidence of dissection. There
is moderate calcified and noncalcified atherosclerosis in the abdominal aorta
and bilateral common iliac arteries. There is moderate, approximately 50%
focal narrowing of the left external iliac artery secondary to calcified and
noncalcified atherosclerotic plaque (series 3A, image 113). The bilateral
common and internal iliac arteries are patent with moderate atherosclerotic
calcification and mild narrowing at the origin of the left internal iliac
artery. The ___ is patent but attenuated (series 3A, image 69). The SMA,
celiac trunk, and ___ are patent.
There is an accessory left hepatic artery arising from the left gastric artery
(series 3A, image 24). There is an accessory right renal artery (Series 3A,
image 46-47). The bilateral renal arteries are widely patent.
CTA Right lower extremity: The right common femoral artery, superficial
femoral artery, and popliteal arteries are widely patent. There is short
segment 2.3 cm long occlusion of the right tibioperoneal trunk (e.g. series 3
B, image 803) with reconstitution immediately distally allowing for an
otherwise normal three-vessel runoff in the right lower extremity. There is
normal posterior tibial and dorsalis pedis blood flow to the right foot.
CTA Left lower extremity: There is multifocal short-segment partial and
complete occlusions of the origin and proximal left superficial femoral artery
measuring 2.1 cm and 2.2 cm long, respectively, which is reconstituted
distally (e.g. series 3A, image 152 - 181). There is also multifocal short
segment occlusions of the left proximal and mid deep femoral artery measuring
approximately 0.7 cm and 1.6 cm, respectively, with reconstitution distally.
The proximal and mid left popliteal artery has areas of segmental complete
occlusion. The below-knee left popliteal artery is not opacified and there is
no evidence of left lower extremity 3 vessel run off on delayed images, which
is likely secondary to extremely slow flow (series 3B, image 832).
LOWER CHEST: Please refer to the dedicated CTA chest from the same day for
description of thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. No evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits, without stones.
There may be a small focal area of gallbladder wall thickening at the fundus
(series 3A, image 47).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. 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 a 2.9 x 2.7-cm left parapelvic cyst (series 3A, image 62). Bilateral
renal cortical hypodensities are too small to accurately characterize on CT,
statistically most likely cysts. Bilateral areas of mild cortical thinning in
the kidneys without adjacent fat stranding are likely chronic sequelae of
prior insults. No evidence of stones, hydronephrosis, or perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is scattered colonic diverticulosis. The
rectum is normal. No pathologically enlarged mesenteric lymph nodes. No
bowel obstruction or free air.
RETROPERITONEUM: No evidence of retroperitoneal lymphadenopathy. No evidence
of retroperitoneal hematoma.
PELVIS: The urinary bladder and distal ureters are unremarkable. No evidence
of pelvic or inguinal lymphadenopathy. No free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is normal in size.
BONES AND SOFT TISSUES: No evidence of worrisome osseous lesions or acute
fracture. A sub cm benign sclerotic lesion in the right hemipelvis is likely
a bone island (series 607b, image 35). A right femoral intra medullary rod
appears intact without evidence of complication. Degenerative changes of both
hips are mild. Multilevel degenerative changes in the visualized lower
thoracic and lumbar spine are moderate. Leftward convex curvature of the
lumbar spine is mild. Tricompartmental degenerative changes the right knee
are moderate. No evidence of joint effusions or ___ cyst. The abdominal
and pelvic wall is within normal limits other than a tiny fat containing
umbilical hernia (series 602b, image 40).
IMPRESSION:
1. Multifocal areas of occlusion involving the origin and proximal left
superficial femoral artery as well as left proximal and mid deep femoral
artery, both reconstituted distally by collaterals.
2. Lack of opacification of the left lower extremity arteries from the
below-knee left popliteal artery to the foot, which is likely due to extremely
slow flow.
3. Short segment occlusion of the right tibioperoneal trunk with
reconstitution immediately distally to allow for an otheriwise normal
three-vessel runoff to the right foot.
4. Colonic diverticulosis.
NOTIFICATION: The findings, impression, and images were discussed with Dr.
___. by ___, M.D. in person on ___ at 4:46 ___, 1
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath
TECHNIQUE: Upright AP view of the chest
COMPARISON: None.
FINDINGS:
Heart size is normal. Mild atherosclerotic calcifications are noted at the
aortic knob. The mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. Lungs are hyperinflated with emphysematous changes
noted. Lungs are otherwise clear without focal consolidation. No pleural
effusion or pneumothorax is identified. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality. Emphysema.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: L Leg pain
Diagnosed with Stricture of artery
temperature: nan
heartrate: 99.0
resprate: 28.0
o2sat: nan
sbp: nan
dbp: nan
level of pain: 3
level of acuity: 1.0 | Mr. ___ was evaluated in the ___ ED for acute left lower
extremity pain with exam and CTA imaging consistent with
diagnosis of acute arterial thrombosis and acute limb threat of
LLE. He was initiated on therapeutic heparin gtt and was
emergently taken to the operating room by Dr. ___ on
___ and underwent L CFA cut down, L SFA and popliteal
thrombectomy. He was extubated and transferred to the PACU, but
given lack of improvement in LLE sensorimotor deficits following
revascularization, the decision was made to proceed with
prophylactic bedside fasciotomies of superficial leg
compartments while in the PACU. Both procedures were well
tolerated and without immediate complications (for further
details regarding these procedures, please refer to the
operative reports). Upon transfer to the floor, patient was kept
on bed rest and his diet was advanced without issue. The Acute
Pain Service was consulted for difficulty managing his pain
postoperatively, and gave recommendations for PO pain regimens
resulting in adequate pain control for the duration of his
hospitalization.
Patient's CPK labs were significantly elevated on POD1, but
these continued to downtrend throughout admission and patient
was maintained on IV fluids for several days postoperatively
without any subsequent evidence of ___. His labs were trended
for several days, without any additional abnormalities noted
during hospitalization.
CT imaging on presentation and subsequent TTE did not
demonstrate source of arterial thrombosis. Heme/Onc Service was
consulted who did not feel that patient's presentation was
consistent with an inherited hypercoagulable state. Thus, given
unknown etiology of arterial thrombosis, the patient was
transitioned from heparin gtt to therapeutic lovenox and bridged
to Coumadin. His INR was initially difficult to maintain in
therapeutic range (goal ___, but he was eventually maintained
on alternating 1 and 2mg daily doses of Coumadin and was
arranged to follow up with a ___ clinic 2 days after
discharge.
LLE fasciotomy sites were serially monitored to assess viability
of muscle groups, which remained stable. Wound vacs were placed
to aid in resolution of edema, at which point Plastic Surgery
Service was consulted for closure of fasciotomy sites. He was
taken to the OR on ___ and underwent primary closure of
medial fasciotomy site, skin graft closure of lateral fasciotomy
(L thigh donor site), with wound vac placement x 5 days. On
POD5, wound vac was taken down and Plastic Surgery recommended
daily dressing changes.
From a neurologic standpoint, patient slowly regained some motor
function of the L toes and with plantar flexion of L ankle, and
some sensation was regained to foot and leg. He was fitted with
a postoperative boot to prevent foot drop and worked with
Physical Therapy in the postoperative period to achieve adequate
mobility with acquired LLE weakness. By the time of discharge,
plastic surgery and physical therapy recommended that the
patient could bear weight as tolerated.
Given that patient did not have health insurance prior to
admission, Social Work and Case Management were involved to
establish PCP follow up for antiocoagulation management in the
outpatient setting. Primary care was established and
antiocoagulation management was arranged with ___
___ prior to discharge.
On POD ___, patient was ambulating with assistance, tolerating
a regular diet, voiding appropriately, his pain was well
controlled, his LLE incisions were clean, dry and intact, his
INR was therapeutic on a stable Coumadin regimen, he had
adequate follow up arranged, and he remained hemodynamically
stable. He was thus deemed ready for discharge home with follow
up scheduled with Dr. ___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pollen/Hayfever / Penicillins
Attending: ___.
Chief Complaint:
Report of delusions and paranoid behavior.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o woman with a history of dementia with psychosis for
several years, diabetes, and recent admission for kidney stones
and a UTI during which she had delirium, but without otherwise
formal psychiatric history who presents with worsening delusions
and paranoia that neighbor is stealing from her, and that kids
are out to get her. Reportedly from ED records, that she was
throwing things at home. She was told she was coming to sign
papers with a lawyer, and was quite disruptive in the ED per
report. Pt upon my questioning denies all of this and does not
remember what happened.
In the ED, initial VS were:T97.7 HR87 BP147/70 RR 20 SaO297% ra
CT head showed No acute intracranial process. Atrophy and
chronic small vessel ischemic disease. Given nitrofurantoin.
Psych saw pt in ED. UTox negative, UA with mild pyuria, no
nitrite or bacteria.
VS on transfer: same as above
Psych c/s: Per patient's and family's report, she has been able
to attend to her ADLs (including cleaning, bathing,
cooking/feeding herself, etc.) despite this worsening paranoia,
though the family is concerned that her current paranoia is
elevating to the point where she is shutting them out of her
life. Because the patient is not suicidal or homicidal and is
attending to her ADLs despite her paranoia, she does not
currently meet ___ criteria. Furthermore, given the
clinical history, the worsening of her paranoia is likely
secondary to delirium as a result of a urinary tract infection
rather than of a worsening primary psychiatric process. The
family remains concerned about her and requests that she be
hospitalized for treatment and further evaluation. Given the
ongoing urinary tract infection, however, we would recommend
that the patient be hospitalized on the medical service for the
time being and followed by the psychiatric consultation service
for consideration of inpatient admission once her UTI is treated
and her delirium resolves.
- Would recommend continuing home medications including Seroquel
25mg PO QHS.
- For acute severe agitation, would recommend Haldol 2.5mg
PO/IM. If requiring >1 chemical restraint, would recommend
rechecking EKG to ensure QTc <450ms.
- For mild agitation, would recommend Seroquel 12.5mg PO BID
PRN.
- Attending psychiatrist will staff case in the morning.
- Please page ___ with further questions.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise unable to obtain
Past Medical History:
HAYFEVER
HYPERGLYCEMIA
HYPERLIPIDEMIA
HYPERTENSION
HYSTERECTOMY
KIDNEY STONES
NON-INSULIN DEPENDENT DIABETES MELLITUS
PEPTIC ULCER DISEASE
Social History:
___
Family History:
+ breast CA.
Psych fhx: - Son: Died from unintentional drug overdose
- Otherwise denies family history mental health problems or
substance abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.5, BP 159/98, HR 55, RR 20, 97/RA
GENERAL: well appearing, sleeping, calm
HEENT: NC/AT, EOMI, sclerae anicteric, MMM
NECK: supple
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, Grade ___ SEM at ___ without radiation
ABDOMEN: normal bowel sounds, soft, slightly tender in
suprapubic area, non-distended, no rebound or guarding, no
masses
EXTREMITIES: 2+ edema halfway up to knees, WWP
NEURO: awake, A&Ox2 (not to time), otherwise MAE, grossly wnl
Discharge exam: Unchanged from above
Pertinent Results:
ADMISSION LABS:
___ 06:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 06:58PM URINE RBC-9* WBC-10* BACTERIA-NONE YEAST-NONE
EPI-1
___ 06:58PM URINE HYALINE-3*
___ 06:58PM URINE CA OXAL-OCC
___ 06:58PM URINE MUCOUS-MANY
___ 04:44PM LACTATE-1.4
___ 04:40PM GLUCOSE-96 UREA N-15 CREAT-0.7 SODIUM-143
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-29 ANION GAP-12
___ 04:40PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-59 TOT
BILI-0.5
___ 04:40PM LIPASE-30
___ 04:40PM ALBUMIN-4.6
___ 04:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:40PM WBC-6.5 RBC-4.16* HGB-10.8* HCT-34.7* MCV-83
MCH-25.8* MCHC-31.0 RDW-13.7
___ 04:40PM NEUTS-78.6* LYMPHS-15.5* MONOS-4.0 EOS-1.2
BASOS-0.6
___ 04:40PM PLT COUNT-250
MICRO:
___ 6:58 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 4:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING/STUDIES:
CT Head Without Contrast ___
TECHNIQUE: Contiguous axial imaging was obtained through the
brain without the administration of intravenous contrast
material. Coronal and sagittalreformats were completed.
COMPARISON: MRI of the head from ___.
FINDINGS:
There is no acute hemorrhage, edema, mass effect or infarction.
The
ventricles and sulci are prominent consistent with atrophy.
There is
periventricular white matter hypodensity consistent with chronic
small vessel ischemic disease. Chronic bilateral basal ganglia
lacunes are also noted. There is a mucous retention cyst in the
right maxillary sinus. The remainder of the visualized
paranasal sinuses, mastoid air cells and middle ear cavities are
clear. There are no acute fractures.
IMPRESSION:
No acute intracranial process. Atrophy and chronic small vessel
ischemic
disease
CHEST RADIOGRAPH ___
INDICATION: Dementia, presenting with acutely worsening
paranoia,
questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. No evidence of pneumonia on the current image. Mild
overinflation with flattened hemidiaphragms and mildly enlarged
cardiac silhouette with tortuosity of the thoracic aorta. No
pleural effusions. No pneumothorax. No pulmonary edema.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Quetiapine Fumarate 25 mg PO QHS
2. Amlodipine 10 mg PO DAILY
hold for sbp<100
3. Lisinopril 40 mg PO DAILY
sbp<100
4. MetFORMIN (Glucophage) 500 mg PO DAILY
with dinner
5. Simvastatin 20 mg PO DAILY
6. traZODONE ___ mg PO HS:PRN insomnia
7. Tamsulosin 0.4 mg PO HS
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
9. Donepezil 5 mg PO HS
10. Docusate Sodium 100 mg PO BID
11. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Donepezil 5 mg PO HS
5. Lisinopril 40 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain
9. Tamsulosin 0.4 mg PO HS
10. Quetiapine Fumarate 37.5 mg PO QHS
RX *quetiapine 25 mg 1.5 tablet(s) by mouth At bedtime Disp #*45
Tablet Refills:*0
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary:
Dementia with psychotic features
Secondary:
Type 2 diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of new onset psychosis and paranoia. Evaluate for
intracranial hemorrhage or mass effect.
TECHNIQUE: Contiguous axial imaging was obtained through the brain without
the administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
COMPARISON: MRI of the head from ___.
FINDINGS:
There is no acute hemorrhage, edema, mass effect or infarction. The
ventricles and sulci are prominent consistent with atrophy. There is
periventricular white matter hypodensity consistent with chronic small vessel
ischemic disease. Chronic bilateral basal ganglia lacunes are also noted.
There is a mucous retention cyst in the right maxillary sinus. The remainder
of the visualized paranasal sinuses, mastoid air cells and middle ear cavities
are clear. There are no acute fractures.
IMPRESSION:
No acute intracranial process. Atrophy and chronic small vessel ischemic
disease
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dementia, presenting with acutely worsening paranoia,
questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. No evidence of pneumonia on the current image. Mild overinflation
with flattened hemidiaphragms and mildly enlarged cardiac silhouette with
tortuosity of the thoracic aorta. No pleural effusions. No pneumothorax. No
pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ? DELUSIONAL
Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 97.7
heartrate: 87.0
resprate: 20.0
o2sat: 97.0
sbp: 147.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ y/o woman with a history of dementia with psychosis for
several years, diabetes, and recent admission for kidney stones
but without otherwise formal psychiatric history who presented
with report of paranoid and delusional thinking.
# Dementia with psychotic features: Patient was brought in by
ambulance after argument with family at home during which she
was agitated and reportedly throwing objects. Her acute
agitation was initially thought to represent toxic-metabolic
encephalopathy/delirium from possible UTI, as below. However,
more likely etiology is worsening of known dementia with some
psychotic features. Patient expressed fixed delusion that her
neighbor was stealing from her and occasionally entering her
house. Details of this are unclear as some family members report
that there is validity to her concerns about the neighbor.
The patient's daughter and son-in-law informed medical team that
patient had been carrying weapons such as a mallet and box
cutters with her at home because of the perceived threat from
her neighbor. Again, the truth of this is unclear and other
family members deny this claim about the patient carrying
weapons. Due to concerns for her safety, a ___ was
initiated ___. Psychiatry was consulted, the patient's home
Seroquel 25mg qHS was increased to 37.5mg qHS.
During her admission, Ms. ___ showed no overt psychotic
behaviors and did not require any extra medications for agitated
or psychotic behavior. Her mood was often very labile and she
continued to report these potentially delusional thoughts about
her neighbor, which are documented in prior notes and do not
appear new or worse than baseline. The patient was alert and
oriented x3 and was able to explain the circumstances of her
hospital admission. It was felt by both the medical and
psychiatry teams that the patient had the capacity to appoint a
health care proxy, and the patient chose to appoint ___ (her
grand-niece). Decision making capacity documented by psychiatry
in ___ OMR note. ___ offered to take the patient into
her home with 24 hour supervision. It was felt that this would
be a safe discharge and the ___ was lifted. The patient
will follow-up with her PCP and her cognitive neurologist after
discharge. Given concern raised by the patient and some family
members that there may be financial abuse by the patient's
daughter (i.e., preventing the patient from selling her house,
asking her to sign checks, etc.), social work referred the
patient for a high risk evaluation by Elder Services. The
patient will also be seen by ___ after discharge. Discharge
plan and legal aspects of the patient's health care proxy were
discussed with ___ legal counsel, ___.
# Pyuria: Patient reported recent vague symptoms of dysuria and
dark urine on admission. UA in ED showed pyuria without
bacteruria. She was initially started on Bactrim pending urine
culture results, especially given recent instrumentation by
urology. Urine culture showed only mixed flora and this was not
felt to be a true UTI, antibiotics were stopped on HD2.
# Type 2 diabetes: On 500 mg of metformin daily with dinner at
home. Last A1C 5.5 ___. Held metformin and treated with
sliding scale insulin while in house. Metformin restarted at
discharge.
# HYPERLIPIDEMIA: Continued on home simvastatin.
# HYPERTENSION - Continued on home amlodipine and lisinopril.
# Anemia: Hct of 34.7 on admission, up from 32 last month.
Consider iron studies as outpatient.
#Transitional issues:
-Will follow-up with PCP and cognitive neurology
-Consider referral for formal neuropsych testing as an
outpatient
-Referral made to elder services to investigate allegations of
financial abuse |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Mediastinal lymph node biopsy
History of Present Illness:
HPI:
Mr. ___ is a ___ year old man with PMHx of HTN, CKD, chronic RUQ
pain s/p numerous ERCP/EUS with benign biopsies c/b pancreatitis
who presented with acute worsening RUQ pain, found to have 13cm
echogenic R renal mass.
He first underwent upper endoscopy for a 2cm mass at the
ampullar of Vater and lesion in the gastric antrum in ___ (both
benign). This procedure was c/b pancreatitis, and he reports he
has had chronic RUQ pain since then. The RUQ pain got notably
worse over the past 3 months, and peaked over the last 3 days.
The pain is constant, does not radiate, and is not associated
with food. He denies n/v, but has had poor appetite ___ pain
and endorses 7lb weight loss over last 4 months. He denies f/c,
night sweats, hematuria, blood in stool. He has had problems
with constipation since ___, for which he takes polyethylene
glycol at home. Given acute worsening of RUQ pain, he was
referred by his GI physician to ___ ___.
Of note, pt was treated for bacterial PNA at ___ ___ on
___ with levofloxacin. He reports cough and back pain
associated with the PNA is improving.
In the ___, initial vitals: 97.9 71 126/71 16 98% RA
- Exam notable for: Crackles at right lower lobe, right upper
quadrant tenderness to moderate palpation. Positive guarding. No
rebound. Left calf tenderness with superficial palpable vessels
appreciated.
- Labs notable for: Cr. 1.4, h/h 12.4/38.3.
- Imaging notable for: negative ___ on the left, RUQ u/s
showing 13.5 x 11.9 x 10.4 cm heterogeneous echogenic mass
arising from the right kidney, concerning for renal cell
carcinoma.
- Pt given: 1L NS, 5mg oxycodone x2
- Vitals prior to transfer: 98.0 82 146/82 16 95RA
On arrival to the floor, pt reports RUQ pain improved with
oxycodone. Last BM was 3 days ago. He also notes new posterior
LLE masses/discomfort of several days.
ROS:
No fevers, chills, night sweats. No changes in vision or
hearing, no changes in balance. No shortness of breath, no
dyspnea on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea. No dysuria or hematuria. No hematochezia,
no melena. No numbness or weakness, no focal deficits.
Past Medical History:
Hypertension
Gastritis
CKD, stage II
Hyperlipidemia
Anemia, folate deficient, possible iron deficient.
GERD
Obesity
Migraine headache
Mass of ampulla of Vater s/p ERCP and EUS with DP in ___ with
negative biopsies and cytology. Surveillance EGD/EUS ___ was
neg. Also noted at that time was a 1cm submucosal gastric
nodule, likely leiomyoma. Benign biopsies
Social History:
___
Family History:
Mother died at old age of renal cancer.
Father died in ___ of Alzeimers.
Multiple early deaths from CAD in siblings (___). Lost one
sister in ___ of brain aneurysm. Son has brain cancer (unknown
type).
Physical Exam:
ADMISSION
=========
Vitals- 97.5 88 128/91 18 94RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear w/o lesions
Neck- supple, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, distended, mild discomfort to deep palpation in
RUQ. Large palpable mass in R flank.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Several 1-2cm nodules/cords palpable on L posterior
calf.
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE
=========
Vitals- 98.38 145/68 69 92-96% RA
General- Awake, alert, oriented, NAD
HEENT- Sclerae anicteric, MMM
Neck- supple, no LAD
Lungs- Distant breath sounds bilaterally, no wheezes, rales,
rhonchi
CV- RRR, Nl S1/S2, ___ systolic ejection murmur most appreciable
at RU sternal border
Abdomen- soft, distended, mild discomfort to deep palpation in
RUQ. Large palpable mass in R flank.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Several 1-2cm nodules/cords palpable on L posterior
calf, decreased in prominence.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION
=========
___ 12:20PM BLOOD WBC-8.1 RBC-4.68 Hgb-12.4* Hct-38.3*
MCV-82 MCH-26.5* MCHC-32.4 RDW-15.4 Plt ___
___ 12:20PM BLOOD Neuts-78.1* Lymphs-12.4* Monos-8.4
Eos-0.8 Baso-0.3
___ 12:20PM BLOOD Plt ___
___ 12:20PM BLOOD Glucose-115* UreaN-14 Creat-1.4* Na-138
K-3.8 Cl-98 HCO3-28 AnGap-16
___ 12:20PM BLOOD ALT-21 AST-24 AlkPhos-68
___ 12:20PM BLOOD Lipase-17
___ 12:20PM BLOOD TotProt-7.1 Albumin-3.8 Globuln-3.3
___ 12:28PM BLOOD Lactate-1.2
MICRO
=====
___ UCx negative
___ BCx
IMAGING
=======
___ RUQUS:
IMPRESSION:
1. 13.5 x 11.9 x 10.4 cm heterogeneous mass arising from the
right kidney, concerning for renal cell carcinoma. Recommend CT
to further assess.
2. Gallbladder sludge. No evidence of acute cholecystitis.
3. Pneumobilia is an expected finding status post ERCP and
sphincterotomy.
___ CXR:
IMPRESSION:
No acute intrathoracic process.
___ ___:
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Superficial venous thrombus within the lesser saphenous vein
of the left lower extremity.
___ CT Chest:
IMPRESSION:
1. Incidentally noted bilateral lobar and segmental pulmonary
emboli with associated dilation of the pulmonary artery and
right heart chambers concerning for acute right heart strain.
2. Mass-like consolidations in the right lower lobe with
associated bronchial wall thickening and secretions may be
related to an infectious process although, in the setting of
pulmonary embolism, infarction is not entirely excluded.
Metastatic disease is considered less likely.
3. Numerous pulmonary nodules throughout both lungs the largest
of which measure 7 mm in the left upper and lower lobes are
worrisome for malignancy. If prior chest CTs are available for
comparison, this would be helpful to determine chronicity.
4. Pathologically enlarged mediastinal lymph nodes concerning
for malignant involvement.
___ CT A/P:
IMPRESSION:
1. 12.4 cm circumscribed right upper pole predominantly cystic
mass renal mass with moderately enhancing multiple mural soft
tissue nodules and papillary projections concerning for a large
cystic papillary renal cell carcinoma. No evidence of renal vein
or collecting system invasion. Note is made of an accessory
right renal artery.
2. A dominant right renal vein is not identified however
multiple collaterals are noted.
3. Indeterminate 7 mm left adrenal nodule which is nonspecific
and not necessarily representative of metastatic disease.
4. 7 mm lucent lesion in the right iliac bone with a thin
sclerotic rim has a benign appearance however recommend close
attention on followup.
5. See separate chest CT report for thoracic findings.
___ CT Head:
IMPRESSION:
1. No acute intracranial abnormality.
2. No mass or pathologic focus of enhancement.
___ MRI Head:
IMPRESSION:
1. No evidence of metastatic disease.
2. No evidence of hemorrhage, infarct, or mass-effect.
3. Brain parenchymal volume loss and presumed sequelae of
chronic small vessel ischemic disease.
___ ECHO:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta 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 appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Normal diastolic function. No pathologic valvular abnormality
seen. Mild pulmonary hypertension.
___ MRI Kidney
IMPRESSION:
1. 12.2 cm right renal mass with MR features favoring clear
cell renal cell carcinoma with hemorrhage. The mass recruits
enlarged feeding vessels from capsular arterial branches. No
evidence of main right renal vein or IVC invasion. Accessory
right renal artery reported on the prior CT is not well
visualized on the current study. No abdominal metastasis
detected. T2b staging by imaging.
2. 13 mm left adrenal adenoma.
3. Small amount of gallbladder sludge.
___ bone scan:
IMPRESSION:
1. No evidence of osseous metastatic disease. Degenerative
changes as described above.
2. Decreased tracer activity within the right kidney to suggest
global
parenchymal dysfunction. If clinically warranted, a renal scan
can be obtained to clarify differential renal function.
DISCHARGE
=========
___ 06:33AM BLOOD WBC-7.3 RBC-3.99* Hgb-10.3* Hct-32.5*
MCV-81* MCH-25.8* MCHC-31.7 RDW-15.7* Plt ___
___ 06:53AM BLOOD ___ PTT-48.3* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 500 mcg PO DAILY
2. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN migraine
3. Amlodipine 5 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Levofloxacin 750 mg PO Q24H
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN migraine
2. Amlodipine 5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Cyanocobalamin 500 mcg PO DAILY
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp
#*10 Capsule Refills:*0
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN
breakthrough pain
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
RX *oxycodone 5 mg ___ capsule(s) by mouth Q4H:prn Disp #*10
Capsule Refills:*0
14. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 100 mg SC every twelve (12) hours Disp
#*14 Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx
Right renal mass
Pulmonary nodules
Mediastinal lymphadenopathy
Bilateral pulmonary embolism
Secondary Dx
Chronic kidney disease
Hypertension
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: A ___ male with a history of ampullary over growth status
post ERCP and sphincterotomy now with right upper quadrant pain.
TECHNIQUE: Gray scale and color Doppler ultrasound images of the abdomen were
obtained and reviewed.
COMPARISON: None.
FINDINGS:
LIVER: Scattered intrahepatic echogenic foci are favored to represent
pneumobilia following prior ERCP and sphincterotomy. The hepatic parenchyma
appears within normal limits.The contour of the liver is smooth. There is no
evidence of concerning focal liver mass. The main portal vein is patent with
hepatopetal flow. An echogenic focus adjacent to the gallbladder measuring up
to 1.0 cm in short axis likely represents a prominent periportal lymph node.
There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is non-shadowing, mobile echogenic material layering
dependently within the gallbladder lumen, compatible with sludge. There is no
evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.1 cm.
KIDNEYS: There is a large, relatively well-circumscribed heterogeneously
echogenic mass arising from the upper pole of the right kidney, measuring 13.5
x 11.9 x 10.4 cm, concerning for renal cell carcinoma. However, minimal
central vascularity is seen. No hydronephrosis. The main right renal vein and
artery are patent. The left kidney measures 9.26 cm. The left kidney
demonstrates normal cortical echogenicity and corticomedullary differentiation
without evidence of concerning solid renal mass, hydronephrosis, or renal
calculus.
RETROPERITONEUM: The visualized portions of the aorta and IVC are within
normal limits.
IMPRESSION:
1. 13.5 x 11.9 x 10.4 cm heterogeneous mass arising from the right kidney,
concerning for renal cell carcinoma. Recommend CT to further assess.
2. Gallbladder sludge. No evidence of acute cholecystitis.
3. Pneumobilia is an expected finding status post ERCP and sphincterotomy.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with recent diagnosis of pneumonia currently
being treated with levofloxacin with right upper qaudrant abdominal pain.
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. The lungs appear hyperinflated and
clear. 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: VENOUS DUP EXT UNI (MAP/DVT) LEFT
INDICATION: ___ man with a history of ampullary overgrowth in the
past status post ERCP and sphincterotomy, now with right upper quadrant pain.
TECHNIQUE: Gray 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, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is non-compressibility and lack of color flow, along with visible
intraluminal echogenic material within the left lesser saphenous vein,
consistent with superficial venous thrombus. There is no involvement of the
popliteal vein.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Superficial venous thrombus within the lesser saphenous vein of the left
lower extremity.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with h/o HTN and CKD p/w worsening RUQ pain found
to have large 13cm renal mass concerning for RCC // eval metastatic disease,
lymphadenopathy
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was administered.
DOSE: DLP: 1868 mGy-cm (abdomen and pelvis.
COMPARISON: Abdominal ultrasound. From ___
FINDINGS:
Please see the dedicated chest CT report from the same day for further details
regarding intrathoracic findings.
ABDOMEN: The liver enhances homogenously without any focal lesions or intra or
extrahepatic biliary dilatation. A small amount of pneumobilia is present in
the left portal vein likely from prior ERCP. The main portal vein is patent.
The gallbladder is distended but there is no gallbladder wall edema or
pericholecystic fluid. The pancreas and spleen are unremarkable. There is a
1.6 x 0.9 cm indeterminate nodule arising from the medial limb of the left
adrenal gland. The left kidney enhances and excretes contrast as expected
without any hydronephrosis. Multiple tiny hypodensities are too small to
characterize.
There is a large 12.2 x 12.4 x 12.4 cm circumscribed heterogeneous mass
arising from the upper pole of the right kidney. The mass is predominantly
centrally hypodense with multiple peripheral mild-moderately enhancing soft
tissue nodules the largest of which arises from the posterior inferior portion
measuring 4.0 x 4.0 cm. The main renal artery is patent and the lower aspect
of the kidney enhances normally. An accessory right renal artery is noted. An
8 mm hypodensity in the lower pole is too small to characterize. A dominant
right renal vein is difficult to identify but multiple collateral venous
structures are present (series 3, image 70).The right adrenal gland appears
unremarkable.
The stomach, small and intra-abdominal large bowel are unremarkable. There is
no free fluid, free air or lymphadenopathy within the abdomen. Mesenteric
stranding along the posterior aspect of the right renal tumor is present. The
aorta is of normal caliber without evidence of aneurysm.
PELVIS: The bladder, prostate gland, rectum and sigmoid colon are
unremarkable. There is no free fluid, free air lymphadenopathy within the
pelvis.
BONES AND SOFT TISSUES: There cortical breakthrough within the right iliac
bone with a 7 mm lucency with a sclerotic rim that has a benign appearance.
(3, 94).
IMPRESSION:
1. 12.4 cm circumscribed right upper pole predominantly cystic mass renal mass
with moderately enhancing multiple mural soft tissue nodules and papillary
projections concerning for a large cystic papillary renal cell carcinoma. No
evidence of renal vein or collecting system invasion. Note is made of an
accessory right renal artery.
2. A dominant right renal vein is not identified however multiple collaterals
are noted.
3. Indeterminate 7 mm left adrenal nodule which is nonspecific and not
necessarily representative of metastatic disease.
4. 7 mm lucent lesion in the right iliac bone with a thin sclerotic rim has a
benign appearance however recommend close attention on followup.
5. See separate chest CT report for thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with large renal mass is concerning for renal
cell carcinoma, here for initial staging.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: DLP: Reported on concurrent CT of the abdomen and pelvis.
COMPARISON: Prior chest radiographs dated ___ and ___. Otherwise, no prior studies are available for comparison.
FINDINGS:
The thyroid is normal. The thoracic aorta is normal in caliber. The main
pulmonary arterial trunk is dilated, measuring 36 mm in diameter (3:32).
Although the study is not as optimal as a CTA for evaluation of the pulmonary
arteries, incidental note is made of bilateral pulmonary emboli involving
lobar arteries of the right upper and lower lobes and a segmental artery of
the right upper lobe as well as at least 2 segmental arteries in the left
lower lobe (3:37). The heart is mildly enlarged with straightening of the
interventricular septum and dilation of the right heart chambers, which may
represent acute right heart strain in the setting of pulmonary emboli.
Coronary and aortic valve calcification is mild. There is no pericardial
effusion.
There are pathologically enlarged mediastinal lymph nodes measuring 17 x 13 mm
in the right upper paratracheal station (3:13), a few measuring 20 x 13 mm in
the aortopulmonary window (03:25), 20 x 12 mm in the right lower paratracheal
station (03:28), 37 x 18 mm in the right lower paraesophageal station (3:34).
Hilar adenopathy is also appreciated on the right greater than the left. No
supraclavicular lymphadenopathy is appreciated. Multiple axillary lymph nodes
bilaterally are not pathologically enlarged.
The airways are normal in caliber. Increased secretions are noted in the
airways of the right lower lobe with bronchial wall thickening. Centrilobular
and paraseptal emphysema is moderate with upper lobe predominance. There are
peripheral nodular opacities in the right lower lobe, which become confluent
with an almost masslike appearance measuring up to 42 x 26 mm (3:45). Numerous
pulmonary nodules are scattered throughout both lungs. For example, 6 mm in
the left lung apex (5:26), 7 x 3 mm in the left upper lobe (5:43), 5 mm left
upper lobe (5:79), 4 mm right upper lobe (5:57, 101), 3 mm right middle lobe
(5:134, 161), 7 mm left lower lobe (5:168), 4 mm lingula (5:184), 6 mm right
lower lobe (5:214, 227). There is no pleural effusion.
There are no osseous destructive lesions concerning for malignancy.
For discussion of intra-abdominal findings, please refer to separate report
from concurrent CT of the abdomen and pelvis.
IMPRESSION:
1. Incidentally noted bilateral lobar and segmental pulmonary emboli with
associated dilation of the pulmonary artery and right heart chambers
concerning for acute right heart strain.
2. Mass-like consolidations in the right lower lobe with associated bronchial
wall thickening and secretions may be related to an infectious process
although, in the setting of pulmonary embolism, infarction is not entirely
excluded. Metastatic disease is considered less likely.
3. Numerous pulmonary nodules throughout both lungs the largest of which
measure 7 mm in the left upper and lower lobes are worrisome for malignancy.
If prior chest CTs are available for comparison, this would be helpful to
determine chronicity.
4. Pathologically enlarged mediastinal lymph nodes concerning for malignant
involvement.
NOTIFICATION: The findings were discussed by Dr. ___ with medical student
___ via telephone on ___ at 12:01 ___, 15 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with HTN, CKD found to have large R renal mass
concerning for RCC with metastatic dz in chest, also found to have bilateral
PEs, and headaches // Assess for brain metastasis, hemorrhage
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 10 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of hemorrhage or mass effect. The ventricles and basal
cisterns appear normal.
There are normal vascular flow voids. There is no evidence of acute infarct
based on diffusion-weighted imaging. There is mild diffuse brain parenchymal
volume loss. There is mild subcortical and periventricular T2/FLAIR signal
hyperintensity within the white matter which is nonspecific though may
represent sequelae of chronic small vessel ischemic disease.
There is no abnormal brain parenchymal or leptomeningeal enhancement.
There is a probable granuloma within the right parietal scalp. There is
bilateral maxillary sinus mucosal thickening. The mastoid air cells and
orbits are unremarkable.
IMPRESSION:
1. No evidence of metastatic disease.
2. No evidence of hemorrhage, infarct, or mass-effect.
3. Brain parenchymal volume loss and presumed sequelae of chronic small vessel
ischemic disease.
Radiology Report
EXAMINATION: CT HEAD W/ AND W/O CONTRAST
INDICATION: ___ year old man with HTN, CKD, R renal mass concerning for RCC,
?pulm mets, incidentally found bilat PEs. Hx of migraines. // Assess for
hemorrhage, masses, mets
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, before and after uneventful intravenous administration of
70 mL Omnipaque 350.
DOSE: DLP (mGy-cm): 1794.24
CTDIvol (mGy): 55.45
COMPARISON: None available.
FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or acute
vascular 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.
There is no pathologic parenchymal, leptomeningeal or dural focus of
enhancement. The principal dural venous sinuses and the major vessels of the
circle of ___ enhance normally and symmetrically.
No fracture or suspicious osseous lesion is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.The
globes are symmetric and unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. No mass or pathologic focus of enhancement.
Radiology Report
EXAMINATION: MRI ABDOMEN W/O AND W/CONTRAST
INDICATION: ___ year old man with HTN, CKD, R renal mass concerning for RCC,
?pulm mets, bilat PEs. // characterization of R renal mass (type of RCC?),
IVC/collecting system involvement, mets
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen were
obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during,
and after the administration of 0.1mmol/kg 10 mL Gadavist gadolinium based
contrast.
COMPARISON: Ultrasound ___, CT ___.
FINDINGS:
A 12.0 x 11.4 x 12.2 cm well-circumscribed mass arises from the right renal
upper pole with areas of internal T1 and T2 hyperintensity likely reflecting
hemorrhage. Peripheral mural solid components are high to intermediate signal
intensity on the T2 weighted images, do not demonstrate significant intra
voxel fat, and avidly enhance after contrast administration. The degree of
enhancement is similar to the normal renal cortex. There is mild mass effect
on the inferior aspect of the liver and the right kidney is displaced
anteromedially. The mass contacts the renal sinus fat without obvious
invasion. The main renal vein appears patent. No mass or thrombus is seen
within the IVC. Vessels surrounding the right adrenal gland are likely due to
enlarged feeding vessels from capsular arterial branches. A
previously-reported accessory right renal artery is not well visualized on the
current study.
There is no hydronephrosis bilaterally. No mass is seen in the left kidney.
Tiny simple cysts are seen bilaterally, measuring up to 7 mm in the left renal
lower pole. The right adrenal gland is normal. A 1.3 cm left adrenal nodule
demonstrates loss of signal on the out of phase images relative to the in
phase images, compatible with an adenoma.
The visualized portions of the liver are unremarkable without focal liver
lesion identified. A small amount of layering sludge is seen within the
gallbladder without wall edema (8: 14). There is no intra or extrahepatic bile
duct dilation. The spleen is unremarkable. The pancreas is normal in signal
intensity and enhancement without focal lesion or and main pancreatic duct
dilation. The visualized portions of bowel are unremarkable. The abdominal
aorta is normal in caliber with mild atherosclerotic plaque along its course.
No enlarged mesenteric or retroperitoneal lymph nodes are identified.
No suspicious osseous lesion is identified. A 5.4 cm lipoma within the left
paraspinal muscles is unchanged.
Right lung opacity (04:22) is better evaluated on prior chest CT.
IMPRESSION:
1. 12.2 cm right renal mass with MR features favoring clear cell renal cell
carcinoma with hemorrhage. The mass recruits enlarged feeding vessels from
capsular arterial branches. No evidence of main right renal vein or IVC
invasion. Accessory right renal artery reported on the prior CT is not well
visualized on the current study. No abdominal metastasis detected. T2b
staging by imaging.
2. 13 mm left adrenal adenoma.
3. Small amount of gallbladder sludge.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RUQ abdominal pain
Diagnosed with ABDOMINAL PAIN RUQ, RENAL & URETERAL DIS NOS
temperature: 97.9
heartrate: 71.0
resprate: 16.0
o2sat: 98.0
sbp: 126.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | ___ with PMHx of HTN, CKD, chronic RUQ pain s/p numerous
ERCP/EUS c/b pancreatitis who presented with acute worsening of
RUQ pain, found to have a large R renal mass concerning for RCC.
# R renal mass: Patient presented with persistent acute on
chronic RUQ pain and found to have a 12.4cm R renal mass
concerning for RCC seen on RUQUS/CT/MRI. MRI characteristics
favor clear cell RCC with hemorrhage. FHx notable for mother
with renal cancer. CT chest showed numerous bilateral pulmonary
nodules and mediastinal LAD concerning for metastatic disease
and a 7mm R lucent iliac bone lesion. MRI head was negative.
Bone scan did not show any metastatic bony lesions. Mediastinal
lymph node biopsy performed on ___ by IP for staging with path
pending. Urology was consulted: if path shows clear cell, pt
will benefit from cytoreductive nephrectomy. Medical oncology
also consulted and will follow up as outpatient. Pain was
initially controlled with oxycodone and this was transitioned to
10mg oxycontin BID and oxycodone as needed for breakthrough.
# PE: CT chest showed incidental finding of bilat segmental PEs
on CT chest. ECHO w/o evidence of RH strain, ischemia. Troponin
and BNP were flat. No evidence of brain hemorrhage/masses (___
brain mets can be hemorrhagic). Patient was initially hypoxic
to 88% on RA which improved to 93% on RA by discharge. He never
felt tachypneic or short of breath. Patiet initially declined
lovenox given prohibitive costs and he was started on heparin
gtt to therapeutic coumadin. However, at discharge, patient
elected to purchase the lovenox and he was discharged with an
INR of 2.9 and instructions to start lovenox the next day.
# ___: Creatinine on presentation was increased to 1.4 from
baseline of 1.1, most likely pre-renal in setting of poor PO
intake ___ abd pain. Resolved with IVFs. Patient received IVF
hydration prior to multiple CT and MRI scans. Patient encouraged
to avoid NSAIDs given CKD and lovenox therapy.
# Constipation: Chronic issue, continued bowel regimen with
miralax, senna, and colace.
# LLE superficial thrombophlebitis: On admission pt c/o L
posterior calf pain and palpable masses. ___ showed
superficial venous thrombus within the lesser saphenous vein, no
DVT. Given increasd risk of proximal progression in setting of
likely malignancy, he was treated with anticoagulation as per
above. NSAIDs were avoided given chronic CKD and ___ as per
above.
# Hypertension: Continued home amlodipine, atenolol.
# GERD: Continued home omeprazole.
# HLD: Continued home simvastatin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Unrestrained Driver in a Motor Vehicle Accident
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male unrestrained driver in a single car motor
vehicle collision who presented to ___ emergency room. He had
a GSC of 15 upon arrival. He had loss of consciousness at the
scene. He presented with upper and lower lip lacerations and
dental injuries and complained of facial and right sided chest
pain. His BAC was elevated at 357. He was pan-scanned in the
Emergency Room and OMFS and Plastic Surgery were consulted as
well as ACS. He was admitted to ___ for further evaluation and
treatment.
Past Medical History:
Depression, Hypertension
Social History:
___
Family History:
Non-Contributary
Physical Exam:
Gen: AAO, NAD
HEENT: Large lip lacerations repaired with sutures. Fractured
teeth. 2cm laceration over R malar eminence repaired with
sutures. + Swelling.
No pain on neck flexion, extension or rotation
___: RRR, S1S2
Chest: Tender to palpation bilaterally
Pulm: CTABL
Abd:+BS, soft, NTND
Ext: No edema. + Abrasian to right knee and left shin.
Pertinent Results:
___ 03:39PM GLUCOSE-143* LACTATE-2.7* NA+-140 K+-3.5
CL--98 TCO2-26
___ 03:30PM UREA N-6 CREAT-0.6
___ 03:30PM estGFR-Using this
___ 03:30PM estGFR-Using this
___ 03:30PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:30PM WBC-7.7 RBC-4.21* HGB-13.2* HCT-40.4 MCV-96
MCH-31.4 MCHC-32.8 RDW-13.3
___ 03:30PM ___ PTT-30.1 ___
___ 03:30PM PLT COUNT-193
CXR ___
Single AP view of the chest was reviewed with no prior studies
available for comparison.
Heart size and mediastinum are grossly unremarkable. Rib
fractures are suspected on the right. No definitive
pneumothorax is seen. Comparison with prior studies is
recommended. Lungs are clear, and no pleural effusion is noted.
CT Chest/Abdomen/Pelvis ___
IMPRESSION:
1. Fractures of the right first and second ribs and left first
rib with small hematoma about the right rib fractures without
evidence of gross vascular injury.
2. Tiny right apical pneumothorax. Small bilateral pleural
effusions, right greater than left with adjacent atelectasis.
3. Esophageal varices, mild splenomegaly, and a heterogeneous
liver with
periportal lymph nodes likely reflect chronic liver disease and
clinical
correlation is recommended.
4. Small amount of complex free fluid about the right upper
quadrant without evidence of solid organ injury may be
attributable to chronic hepatic disease.
5. Featureless sigmoid colon with wall thickening could be due
to underlying colitis. Recommend clinical correlation.
6. Gallstones.
CT Sinus/Mandible/Maxil
IMPRESSION:
1. Probable tooth fragments within the right upper and mid lip.
2. Fractured maxillary incisor teeth.
3. Chronic fracture of the left lamina papyracea. Mildly
displaced left nasal bone fracture and probable fracture of the
anterior nasal spine are
age-indeterminate.
CT Head
Final Report
INDICATION: Trauma, injury to the face with broken teeth.
COMPARISON: None at this time.
TECHNIQUE: Axial MDCT images were obtained through the brain
without IV
contrast. Multiplanar axial, coronal, sagittal, and thin
section bone
algorithm reconstructed images were generated.
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, mass effect or large territorial infarction. Ill-defined
hypodensity in the white matter of the right frontal lobe likely
reflects the sequela of chronic microvascular infarction. The
ventricles and sulci are normal in size and configuration for
the patient's age. The basal cisterns are patent and there is
preservation of gray-white differentiation.
There is no acute fracture detected. Deformity of the left
lamina papyracea
and left nasal bone appears to be remote. Mild mucosal
thickening is noted
involving the right maxillary and left sphenoid sinuses. The
mastoid air
cells, middle ear cavities and remaining visualized paranasal
sinuses are
clear. The globes are grossly intact.
IMPRESSION: No other acute intracranial abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. TraZODone 100 mg PO HS
3. QUEtiapine Fumarate Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4 hours Disp #*30
Tablet Refills:*0
3. QUEtiapine Fumarate 100 mg PO PRN voices
4. TraZODone 100 mg PO HS
5. Peridex (chlorhexidine gluconate) 0.12 % mucous membrane BID
RX *chlorhexidine gluconate 0.12 % Rinse twice a day Disp #*4
Fluid Ounce Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Accident with upper & lower lip lacerations, nasal
bone frx, superfical dental injuries, R C7 transverse process
fracture, Right 1st rib, Left ___, & 9th rib fractures and
a tiny Right apical Pneumothorax.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Trauma, injury to the chest.
TECHNIQUE: Supine AP view of the chest.
COMPARISON: None.
FINDINGS:
Exam is somewhat limited due to overlying trauma board. The lung volumes are
low. The heart size is mildly enlarged. The mediastinal and hilar contours
are unremarkable. Patchy opacity within the left lung base could reflect
atelectasis. No large pleural effusion or pneumothorax is seen on this supine
exam. Fractures of the 1st ribs bilaterally as well as the 2nd rib on the
right are noted.
IMPRESSION:
1. Patchy opacity in the left lung base could reflect atelectasis.
2. Fractures of the 1st ribs bilaterally and right 2nd rib.
Radiology Report
INDICATION: Trauma, injury to the face with broken teeth.
COMPARISON: None at this time.
TECHNIQUE: Axial MDCT images were obtained through the brain without IV
contrast. Multiplanar axial, coronal, sagittal, and thin section bone
algorithm reconstructed images were generated.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, mass effect
or large territorial infarction. Ill-defined hypodensity in the white matter
of the right frontal lobe likely reflects the sequela of chronic microvascular
infarction. The ventricles and sulci are normal in size and configuration for
the patient's age. The basal cisterns are patent and there is preservation of
gray-white differentiation.
There is no acute fracture detected. Deformity of the left lamina papyracea
and left nasal bone appears to be remote. Mild mucosal thickening is noted
involving the right maxillary and left sphenoid sinuses. The mastoid air
cells, middle ear cavities and remaining visualized paranasal sinuses are
clear. The globes are grossly intact.
IMPRESSION: No other acute intracranial abnormality.
Radiology Report
INDICATION: Trauma, facial injury and neck pain.
COMPARISON: None.
TECHNIQUE: Contiguous helical MDCT images were obtained from the skull base
through the T1 level without IV contrast. Multiplanar axial, coronal,
sagittal and thin section bone algorithm images were generated.
FINDINGS: Mildly displaced fracture of the right C7 transverse process is
noted. No subluxation is detected. The prevertebral soft tissues are normal.
The atlantodental interval is preserved. The dens is normally positioned
between the lateral masses of C1. There are mild degenerative changes with
anterior and posterior osteophytes. Disc osteophyte complexes cause mild
central canal narrowing at the C5-C6 level. There are atherosclerotic
calcifications at the bifurcations of the common carotid artery.
IMPRESSION: Fracture of the right C7 transverse process. Mild degenerative
changes as detailed above.
Results communicated to ___ in person by ___ at 4:20 pm,
___, at time of finding.
Radiology Report
INDICATION: Trauma, facial injury.
COMPARISON: None.
TECHNIQUE: Contiguous helical MDCT images were obtained through the orbits
and face without IV contrast. Multiplanar axial, coronal, sagittal, and thin
section bone algorithm reconstructed images were generated.
FINDINGS:
There is a minimally displaced left nasal bone fracture of indeterminate age.
There is mild soft tissue swelling over the right frontal bone and right
cheek. Extensive soft tissue swelling is noted about the right upper and lower
lips. There are two approximately 5 mm hyperdense foci in the upper lip,
presumably tooth fragments (3:80) as the maxillary central incisor teeth and
left maxillary lateral incisor appear to be missing their crowns. There are
tiny fragments adjacent to the anterior nasal spine, suggestive of fracture,
but age indeterminate. There is evidence of old lamina papyracea fracture on
the left with a small focus of fat herniation (401B:68). No acute orbital
fracture is detected. There is mild mucosal thickening of the maxillary,
ethmoidal and sphenoid sinuses. The partially visualized mastoid air cells
are clear. The middle ear cavities are clear. No other fracture is detected.
Periapical lucency about the left central maxillary incisor suggests
periodontal disease.
IMPRESSION:
1. Probable tooth fragments within the right upper and mid lip.
2. Fractured maxillary incisor teeth.
3. Chronic fracture of the left lamina papyracea. Mildly displaced left nasal
bone fracture and probable fracture of the anterior nasal spine are
age-indeterminate.
Radiology Report
INDICATION: ___ man with trauma, rib pain.
COMPARISON: None.
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest,
abdomen and pelvis after administration of 130 cc of Omnipaque IV contrast.
Multiplanar axial, coronal, and sagittal images were generated.
FINDINGS:
CT CHEST: There are minimally displaced fractures of the right anterior first
rib, and right posterior second rib. There is fracture of the left
anterolateral first rib. There is a small hematoma surrounding the right rib
fractures (2:5). However, there is no evidence of gross vascular injury.
Small right apical pneumothorax is present. There are small bilateral pleural
effusions, right greater than left with adjacent compressive atelectasis
posteriorly.
The airways are patent to the subsegmental level. The heart is not enlarged
and there is no pericardial effusion. The great vessels are within normal
limits. The aorta is not dilated. There is no pericardial effusion. The
partially visualized thyroid contains a subcentimeter cyst. There is no
mediastinal, hilar, axillary or supraclavicular lymphadenopathy.
CT ABDOMEN: There are esophageal varices and small amount of fluid around
the liver, IVC and right adrenal gland which is mildly complex. No solid
organ injury is detected. The liver is mildly heterogenous and there are
scattered periportal lymph nodes. The spleen is homogenous and enlarged
measuring 14 cm. These findings may be sequela of chronic liver disease. No
focal liver lesions are noted.
There is no intra- or extra-hepatic biliary duct dilation. The portal and
splenic veins are patent. There are numerous gallstones in the gallbladder,
which is not dilated and shows no mural thickening or pericholecystic fluid.
The adrenal glands are unremarkable. The kidneys excrete contrast promptly
and symmetrically. The ureters are normal throughout their visualized course.
A small hypodensity in the interpolar region of the left kidney is too small
to characterize, but is likely a simple cyst.
The stomach, duodenum and small bowel are within normal limits, without wall
thickening or evidence of obstruction. Of unclear etiology, the sigmoid up to
the level of the left colon is somewhat featureless with wall thickening
(2:101), which could be due to underlying colitis. There is no free air or
abdominal wall hernia detected. The abdominal vasculature is unremarkable.
CT PELVIS: There is no free fluid. The pelvic organs are unremarkable
including the prostate and bladder. There is no pelvic wall or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: Aside from the fractures detailed above, there is no
concerning blastic or lytic lesion. Right ninth anterior rib fracture appears
subacute to chronic.
IMPRESSION:
1. Fractures of the right first and second ribs and left first rib with small
hematoma about the right rib fractures without evidence of gross vascular
injury.
2. Tiny right apical pneumothorax. Small bilateral pleural effusions, right
greater than left with adjacent atelectasis.
3. Esophageal varices, mild splenomegaly, and a heterogeneous liver with
periportal lymph nodes likely reflect chronic liver disease and clinical
correlation is recommended.
4. Small amount of complex free fluid about the right upper quadrant without
evidence of solid organ injury may be attributable to chronic hepatic disease.
5. Featureless sigmoid colon with wall thickening could be due to underlying
colitis. Recommend clinical correlation.
6. Gallstones.
Radiology Report
HISTORY: Possible retained tooth fragment in the upper lip.
TECHNIQUE: 2 views of the facial bones.
COMPARISON: CT facial bones ___ at 15:55.
FINDINGS:
Within the upper lip, there is approximately 5 mm triangular ossific density
likely reflecting a retained tooth fragment. The central maxillary incisors
appear to have been fractured through their crowns. Subcutaneous gas is noted
within the soft tissues anterior to the mandible.
Radiology Report
REASON FOR EXAMINATION: Small right apical pneumothorax.
Single AP view of the chest was reviewed with no prior studies available for
comparison.
Heart size and mediastinum are grossly unremarkable. Rib fractures are
suspected on the right. No definitive pneumothorax is seen. Comparison with
prior studies is recommended. Lungs are clear, and no pleural effusion is
noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with TRAUM PNEUMOTHORAX-CLOSE, FRACTURE FOUR RIBS-CLOSE, FX DORSAL VERTEBRA-CLOSE, OPEN WOUND OF LIP, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, MV COLL W OTH OBJ-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was admitted to the acute care surgery & trauma
service after he had sustained multiple injuries in a single car
MVC thought to be related to alcohol. His injuries included:
Right ___ and rib fractures, Left first rib fracture, upper and
lower lip laceration, nasal bone fracture (age indeterminate),
dental injuries and a C7 transverse process fracture. He also
had a very small right apical pneumothorax. CT head demonstrated
a small hypodensity in the Right frontal lobe thought to be
chronic in nature.
Plastic Surgery closed the facial and lip lacerations. OMFS was
consulted for his dental trauma and they recommended peridex and
follow-up with his outpatient dentist.
On Hospital day 2, his tertiary survey was completed with no
additional injuries found. He had no signs or symptoms of
cervical instability on exam, and his cervical collar was
removed. He initially had some nausea and small emesis, but
later tolerated a regular diet without difficulty. He was
ambulating and voiding without difficulty. His pain was well
controlled on oral medications. A chest X-ray to follow-up on
his small right pneumothorax found on CT demonstrated no
pneumothorax. After reviewing all of his radiology reports, he
was considered safe for discharge with follow-up. He is to
follow-up with ACS in 2 weeks, to follow-up with Plastic Surgery
on ___ for suture removal and follow-up with
his dentist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx bipolar disorder who presented to the ED with suicidal
ideation.
He presented into the ED without shoes or a shirt. He reportedly
gave a confusing history of emotional trauma following a trip to
___ this past ___ with episodes over the weekend where he
felt as if he was dying from several hours of intermittent chest
pain that self-resolved without intervention. He reports feeling
like he was going to die this morning and therefore ran out of
his house to the ED. He reports that he has been off his home
___ and has not slept the 3 days prior to presentation.
Per the ED and Psychiatry team, he also has reported feeling
more isolated, disorganized and paranoid with increasing
inability to care for himself. He denies taking drugs but does
endorse ETOH although it is unclear how much or when.
In the ED, initial vitals were 98, ___, 18, 99% on RA.
He received multiple doses of diazepam and risperdal with which
his vitals improved ti 98, 71, 126/84, 15, 100% on RA. Labs
including serum and urine tox were all wnl. CXR was negative and
EKG was reassuring. The patient was evaluated by Psych who felt
that he would benefit from inpatient psychiatric
hospitalization.
Upon arrival to the floor, intiial VS 98.3, 127/79, 72, 16, 100%
on RA. Patient denies any symptoms of abdominal pain or chest
pain currently.
Past Medical History:
-Bipolar D/O
-Schizophrenia
-Hyptertriglyceriiemia
-Obesity
-Vitamin D Deficiency
Social History:
___
Family History:
No family history of psychiatric disease
From Dr. ___ ___
Mother Living ___ SKIN CANCERS
BREAST CANCER
THYROID NODULE
URINARY FREQUENCY
DIVERTICULOSIS s/p partial colon
resection
Father Unknown
MGM ___ ___ ABNORMAL LIVER
FUNCTION TESTS
STOMACH CANCER
HYPERTENSION
MGF Deceased ___ EAR, NOSE & THROAT
DIABETES MELLITUS
HYPERTENSION
CORONARY ARTERY
DISEASE
PGM Deceased ___ NATURAL DEATH
PGF Deceased ___ ALCOHOL ABUSE
LIVER DISEASE
Comments: 2 brothers and 1 sister alive and healthy.
Physical Exam:
ADMISSION EXAM
Vitals: 98.3, 127/79, 72, 16, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: 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: AOx3, moving all extremities spontaneously.
DISCHARGE EXAM
VS - 97.8 134/79 88 16 100% on RA
General: WD/WN overweight male in NAD, laying in bed
HEENT: EOMI, PERRL, anicteric sclera, MOM, clear oropharynx
Neck: supple, non-tender, no JVD
CV: soft HS, S1S2, no M/R/G
Lungs: CTAB, no W/R/R
Abdomen: soft, NT, ND, no HSM, nl BS
Ext: peripheral pulses 2+, no cyanosis, edema
Neuro: alert, sad sometimes tearful affect, appropriate,
congruent, positive for blocked speech and psychomotor slowing,
denies current SI, SILT throughout, no gross motor deficits, no
rigidity in BUE, no DDK.
Skin: no rashes, bilateral hematoma on heels of both feet
Psych: no suicidal ideation, answers questions without
tangientiality or circumstantiality, unclear recounting as to
motivations/thinking behind stopping medications
Pertinent Results:
ADMISSION
___ 02:50PM BLOOD WBC-7.6 RBC-5.23 Hgb-14.5 Hct-42.9 MCV-82
MCH-27.7 MCHC-33.8 RDW-12.9 RDWSD-37.8 Plt ___
___ 02:50PM BLOOD Neuts-71.6* Lymphs-18.5* Monos-8.2
Eos-1.1 Baso-0.3 Im ___ AbsNeut-5.43 AbsLymp-1.40
AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02
___ 02:50PM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-24 AnGap-17
___ 02:50PM BLOOD Valproa-78
___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 03:20PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:20PM URINE Mucous-FEW
___ 03:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 500 mg PO BID - had stopped on
his own
2. RISperidone 3 mg PO DAILY - had stopped on his own
Discharge Medications:
1. RISperidone 2 mg PO QHS
2. Divalproex (DELayed Release) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Schizophrenia
- Bipolar affective disorder
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 intermittent episodes of chest pain
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. No focal consolidation, pleural effusion or
pneumothorax is present. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: SI, L Chest pain
Diagnosed with PSYCHOSIS NOS
temperature: 98.0
heartrate: 118.0
resprate: 18.0
o2sat: 99.0
sbp: 178.0
dbp: 139.0
level of pain: 10
level of acuity: 2.0 | ___ year old male who had had stopped his riperisone and valproic
acid for unclear reasons prior to an emotional episode ___
complicated by unclear amount of alcohol intake through ___ who
experienced intermittent mid-sternal chest pain/pressure for 3
days with no associated symptoms but had a fear of dying and ran
to the ED without shoes or shirt. He had negative EKG and tox
screen in ED, but presented with BP into 170s/140s requiring
multiple doses of diazepam and risperdal. Psych felt he would
benefit from inpatient psychiatric hospitalization. He was
transfered to the medicine floor afebrile, hemodynamically
stable, normotensive to await placement at an ___
facility.
ACTIVE ISSUES
# Bipolar disorder vs schizophrenia. Followed by Dr. ___
___. Patient met ___ criteria. Psychiatric
consultant thought patient would benefit from inpatient
psychiatric hospitalizatoin. He is medically cleared from out
standpoint. Restarted Risperdal at 2 mg QHS and Depakote 500 XR
BID. Patient did not require any chemical restraints on the
medicine floor.
TRANSITIONAL ISSUES
- recommend monitoring EKG for QTc prolongation if requires
multiple antipsychotics as chemical restraints or large changes
in medication doses. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Shaking Episode
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC:Shaking Episode
.
HPI: Mr. ___ is a ___ yo man with CKD stage III, HTN,
HLD,
BPH, Hypercalcemia/hyperparathyroidism, who presents after on
episodes of chills/rigors and worsening of his chronic weakness.
He states it has been a hard winter for him with a constant cold
for the last three months. He states over that time he had a dry
cough but no phlem. A few days ago he noticed the cough was
getting worse and he began to cough up clear phlem. One day ago
he was having cold sweats and began to have worsening chills.
Last night he began to sweat profusely and shortly after this he
was noted to have shaking of his arms and legs and mouth. His
girlfriend call ___ as she thought he was having a seizure.
During the episode he was incontinent of urine. After the
episode
he was noted to be confused and wasn't answering questions.
He denies any known fevers, sick contacts. He denies any chest
pain, shortness of breath.
In the ED vitals were initially Hr 72, BP 148/76, RR16, O2Sat
94.
He was then placed on 2L NC. Initially there was concern the
this
might hve been a first seizure so he had a head CT which showed
chronic microangiopathy but no acute abnormalities. Neurology
was
consulted and felt this was more likely rigors and did not
recommended an EEG. his labs were remarkable for WBC 10.0, UA
negative, flu swab negative. CXR was read as possible pneumonia
and he was started on ceftriazone and azithromycin. He continued
to feel weak and was admitted for a ___ consult.
On arrival to the floor he is feeing significantly better and no
longer confused. He feels the cough is improved as well. He
feels
he is still much below his baseline strength and feels more
tired
than usual.
ROS: 14 point ROS negative except per HPI
.
Past Medical History:
1. Essential hypertension
2. Hypercholeserolemia
3. Chronic Kidney Disease Stage III
4. Sickle cell trait
5. Sensorineural hearing loss
6. Spinal stenosis of lumber region s/p laminectomy and lumbar
fusion
7. BPH
8. Tobacco abuse
Social History:
___
Family History:
Mother with Type ___ DM
Sickle cell disease
Physical Exam:
Gen: Lying in bed in no apparent distress
Vitals:T97.7, BP 131/82, HR 62, RR17, O2sat 95% RA
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 06:55AM BLOOD WBC-8.1 RBC-4.46* Hgb-12.6* Hct-38.2*
MCV-86 MCH-28.3 MCHC-33.0 RDW-15.6* RDWSD-48.5* Plt ___
___ 06:30AM BLOOD WBC-8.4 RBC-4.63 Hgb-13.0* Hct-39.6*
MCV-86 MCH-28.1 MCHC-32.8 RDW-15.8* RDWSD-48.7* Plt ___
___ 06:55AM BLOOD Glucose-96 UreaN-21* Creat-1.3* Na-142
K-4.0 Cl-105 HCO3-25 AnGap-16
___ 03:14AM BLOOD CK(CPK)-201
___ 06:30AM BLOOD Calcium-10.9* Phos-3.0 Mg-2.2
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of
the ventricles
and sulci suggestive of involutional changes. Ill-defined
periventricular and
subcortical white matter hypodensities, right greater than left,
are
nonspecific but likely due to sequela of chronic small vessel
ischemic
disease. An old lacunar infarct is noted in the left basal
ganglia.
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 major intracranial abnormalities.
2. Chronic microangiopathy and age related global atrophy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Gabapentin 300 mg PO BID
3. Allopurinol ___ mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. Simvastatin 20 mg PO HS
7. Terazosin 2 mg PO HS
8. Torsemide 5 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Simvastatin 20 mg PO HS
8. Terazosin 2 mg PO HS
9. Torsemide 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#CAP
#Shaking Episode
#Weakness
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: History: ___ with rigors and cough// r/o pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Opacities in the left lower lobe can be concerning for early infection. There
is mild pulmonary vascular congestion without overt edema. No pneumothorax or
pleural effusion. The cardiomediastinal silhouette and hilar contours appear
unchanged.
IMPRESSION:
Opacities in the left lower lobe can be concerning for early infection.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with AMS// eval for 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 16.0 s, 16.0 cm; CTDIvol
= 50.2 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. Ill-defined periventricular and
subcortical white matter hypodensities, right greater than left, are
nonspecific but likely due to sequela of chronic small vessel ischemic
disease. An old lacunar infarct is noted in the left basal ganglia.
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 major intracranial abnormalities.
2. Chronic microangiopathy and age related global atrophy.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: 96.2
heartrate: 68.0
resprate: 20.0
o2sat: 93.0
sbp: 154.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ yo man with CKD stage III, HTN, HLD, BPH,
Hypercalcemia/hyperparathyroidism, who presents after on
episodes
of chills/rigors found to have possible LLL community acquired
pneumonia now improving.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Abdominal Pain, nausea, vomiting
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
___ with 2 days nausea, vomiting, and right lower quadrant pain
with CT scan suspicious for appendicitis. Patient has a history
of diverticulitis which was treated as an outpatient ___ years
ago. Pain started ___ with nausea, non bloody, non bilious
vomiting, subjective fevers and chills and anorexia. He has been
passing gas and had a non bloody bowel movements during that
time. Went to primary care provider today who referred him to
the emergency department.
Past Medical History:
HIV, diverticulitis ___ years ago treated as outpatient,
migraines, hyperlipidemia, depression, anxiety
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission physical Exam:
VS: 99.0 87 121/79 15 97%Ra
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR,
PULM: CTA B/L no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: RLQ tenderness, no rebound, + obtruator
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Discharge Physical Exam:
97.9, 77, 114/65, 18, 99% RA
HEENT: No deformity. PERRL. EOMI. Mucus membranes moist.
CV: RRR
Pulm: CTA bilaterally.
GI/GU: Abdomen soft, mild tenderness at umbilicus as
anticipated, non-distended. Active bowel sounds x 4 quadrants.
Skin: Laparoscopic incisions with glue to abdomen. edges well
approximated, no redness or drainage.
Ext: Warm and dry. no edema.
Neuro: A&Ox3. Moves all extremities equal and strong. Speech is
clear and fluent.
Pertinent Results:
___ 11:45AM BLOOD WBC-8.0 RBC-4.88 Hgb-14.9 Hct-43.0 MCV-88
MCH-30.5 MCHC-34.7 RDW-12.5 RDWSD-40.2 Plt ___
___ 11:45AM BLOOD Neuts-62.6 ___ Monos-11.8
Eos-0.5* Baso-0.2 Im ___ AbsNeut-5.03 AbsLymp-1.97
AbsMono-0.95* AbsEos-0.04 AbsBaso-0.02
___ 11:45AM BLOOD Glucose-115* UreaN-10 Creat-0.9 Na-138
K-5.7* Cl-100 HCO3-27 AnGap-17
___ 11:56AM BLOOD Lactate-2.0 K-3.7
___ 02:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:20PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ CT abd/pelvis
1. Acute uncomplicated appendicitis.
2. Mild splenomegaly.
Medications on Admission:
Crestor 10 mg daily, Atripla 1 tab daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain/fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Take lowest effective dose.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluate for diverticulitis or appendicitis in a patient with
right lower quadrant pain with rebound tenderness x2 days.
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) = 891 mGy-cm.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis. There is no pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in attenuation, without focal lesion
or intra or extrahepatic biliary duct dilation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is homogeneous, without focal lesion. There is mild
splenomegaly, with the spleen measuring 14.2 cm.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally.
URINARY: The kidneys are symmetric and normal in size, demonstrating normal
nephrograms and excreting contrast promptly. There is no evidence of focal
renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed, without obvious wall thickening
or mass. Small bowel is normal in caliber, without wall thickening or
evidence of obstruction. There is mild diverticulosis of the descending colon
without acute diverticulitis. The appendix is dilated, measuring 8 mm, with
wall thickening, hyperemia, and periappendiceal inflammation compatible with
acute appendicitis. There is no extraluminal gas or fluid collection.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable. Calcification of the vas
deferens is noted.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no focal lytic or sclerotic osseous lesion to suggest neoplasm
or infection.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute uncomplicated appendicitis.
2. Mild splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 98.9
heartrate: 103.0
resprate: 18.0
o2sat: 99.0
sbp: 126.0
dbp: 78.0
level of pain: 7
level of acuity: 3.0 | The patient is a ___ HIV-positive gentleman admitted to
the Acute Care Surgery Service on ___ with a 2-day history
of right lower quadrant pain. CT scan showed acute nonperforated
appendicitis. Informed consent was obtained and he was taken to
the operating room for a laparoscopic appendectomy. Please see
operative report for details. The patient was extubated, taken
to the PACU until stable, then transferred to the floor for
further managment.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV morphine
and then transitioned to oral oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: On POD1, the diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored. He voided spontaneously without
issues.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stone extraction
History of Present Illness:
Mrs ___ is a ___ with pAF on Coumadin, HTN, GERD, anxiety,
and cholelithiasis s/p CCY last year who presented to ___ with
epigastric abdominal pain and was transferred to ___ out of
concern for gallstone pancreatitis.
She was in her usual state of good health until ___ days ago
when she noticed epigastric pain, something between gassy and
gnawing, nonradiating, moderate intensity, in the mornings. She
would belch, pass flatus, have BM, and it would subside.
However, on the day of presentation she developed a similar
pain, but it became progressively worse instead of resolving.
She then developed a profound sense of fatigue and weakness, and
her husband became worried and called EMS, who took her to ___.
Labs at ___ were consistent with pancreatitis, elevated LFTs.
Report of tachycardia initially, but initial EKG reported as HR
___ in SR. No report of fevers. She was given 2L IVF, Zofran,
morphine, and Zosyn. CT performed, report not sent with pt, per
records "suggests CBD involvement." She was transferred to ___
as ERCP services were not available until ___. No labs were
transmitted with the patient.
Here, she had stable vital signs. Labs confirmed transaminitis
and lipasemia. No CBC was sent. INR 3.2. CXR was interpreted as
"possible pneumonia" and she was ordered for Levaquin -- not
actually given in ED but finished on the floor after arrival.
She was otherwise given 2L NS and morphine.
Here, she has no complaints apart from mild abdominal pain
similar to that described above, along with very dry mouth. No
f/c/s, n/v, cough/cp/sob.
ROS is negative in 10 points except as noted above
Past Medical History:
PMH: pAF on Coumadin, HTN, GERD, anxiety, and cholelithiasis
PSH: CCY, appendectomy
Social History:
___
Family History:
No family history of GI malignancy or gallstones that she knows
of
Father died of leukemia
Mother died of stroke at an old age
Physical Exam:
Vitals AVSS, came to us on some supplemental O2, weaning quickly
Gen NAD, quite pleasant
Abd soft, NT, ND, bs+
CV RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
Psych normal affect
Pertinent Results:
Labs on admission:
___ 11:50PM BLOOD ___ PTT-32.1 ___
___ 11:50PM BLOOD Glucose-162* UreaN-13 Creat-0.9 Na-135
K-3.1* Cl-96 HCO3-25 AnGap-17
___ 11:50PM BLOOD ALT-292* AST-617* AlkPhos-151*
TotBili-3.4* DirBili-2.7* IndBili-0.7
___ 11:50PM BLOOD Lipase-845*
___ 11:50PM BLOOD Albumin-3.6
___ 12:02AM BLOOD Lactate-2.5*
Imaging here
RUQUS -
1. CBD dilatation up to 1.7 cm in the region of the pancreatic
head. Mild
intrahepatic biliary dilatation. No ductal stone detected.
2. Post cholecystectomy.
CXR - no acute process
EKG
RBBB, inferior q, otherwise no overt ischemic changes
ERCP ___:
Impression: The scout film was normal.
A single non-bleeding diverticulum with small opening was found
on the rim of the major papilla.
Cannulation of the biliary duct was performed using a free-hand
technique.Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the main duct, left
main hepatic duct and right main hepatic duct with the CBD
measuring 15 mm.
There was no evidnece of biliary stricture causing the upstream
dilation.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Evidence of post sphincterotomy mild oozing was noted, 6 cc of
epinephrine were injected with stop oozing.
Balloon sweeps were performed multiple times with extraction of
small amount of sludge.
Post balloon sweeps good contrast drainage was noted both
endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Recommendations: NPO overnight with aggressive IV hydration
with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Return to ward under ongoing care.
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Please refer the patient for further evaluation with MRI/MRCP
in 1 month
Follow Hgb/HCT trend
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
INR last checked on ___ was 1.4
Total bilirubin normalized
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 08:05 135* 77* 106* 73 1.4
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
Plt Ct
___ 08:20 11.0* 3.32* 10.7* 31.5* 95 32.2* 34.0 13.5
47.1* 129*
Plts rising throughout hospitalization, WBC falling; suspect
both were from bloodstream infection, improving with ongoing
therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6.5 mg PO DAILY16
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
3. atenolol-chlorthalidone 50-25 mg oral DAILY
4. Dronedarone 400 mg PO BID
5. Famotidine 20 mg PO BID
6. Ramipril 2.5 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
last dose is on ___, following this Midline (IV) should be
removed
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV Daily
Disp #*12 Intravenous Bag Refills:*0
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
3. Dronedarone 400 mg PO BID
4. Famotidine 20 mg PO BID
5. atenolol-chlorthalidone 50-25 mg oral DAILY
6. Ramipril 2.5 mg PO DAILY
7. Warfarin 6.5 mg PO DAILY16
DO NOT TAKE UNTIL ___ AS WE DISCUSSED. NEXT INR CHECK ON
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gallstone Pancreatitis
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 elevated lipase, CT scan showing possible CBD dilation.
?CBD dilation, ?stone
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside hospital CT abdomen of ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation. The CBD is dilated,
measuring up to 1.7 cm in the region of the pancreatic head, beyond which it
is not visualized by ultrasound due to shadowing.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas. No discrete mass identified at the
pancreatic head, although evaluation is slightly limited.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. CBD dilatation up to 1.7 cm in the region of the pancreatic head, beyond
which it is not visualized by ultrasound secondary to obscuration by overlying
bowel gas shadowing. Therefore the cause of dilatation is not identified on
this exam alone.
2. Mild intrahepatic biliary dilatation. No ductal stone detected.
3. Post cholecystectomy.
RECOMMENDATION(S): Further evaluation with ERCP or MRCP could be considered.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with new oxygen requirement. Evaluate for acute
cardiopulmonary process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside hospital CT abdomen of ___.
FINDINGS:
Lung volumes are slightly low, accentuating the cardiomediastinal silhouette.
Bibasilar atelectasis is noted, right greater than left, confirmed on the
outside hospital CT. No focal consolidation or pneumothorax. Pleural
effusions are trace, if any.
IMPRESSION:
Low lung volumes with bibasilar atelectasis. No pneumothorax or focal
consolidation. Mild pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Acute pancreatitis, unspecified
temperature: 99.5
heartrate: 78.0
resprate: 18.0
o2sat: 94.0
sbp: 134.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | ___ y/o F with PMHx of Afib on Coumadin, HTN, GERD, as well as
prior cholelithiasis s/p CCY, who was transferred here for
concern for gallstone pancreatitis.
# Choledocholithiasis / Bile Duct Obstruction / Pancreatitis:
Per report, OSH CT showing "CBD involvement". RUQ U/S here
showing CBD dilatation. ERCP initially delayed ___ elevated INR,
but was completed following INR reversal with vitamin K. Report
as above. Pt. tolerated procedure well and diet was advanced
following without difficulty.
# GNR Bacteremia: due to biliary obstruction and bile duct
infection. Pt was placed on IV zosyn pending speciation /
sensitivities. Ultimately found to have e coli, resistant to
fluoroquinolones, ampicillin. ___ to ceftriaxone. Started on
2 grams daily of ceftriaxone for planned ___ mid
line (placed). Home infusion arranged. will have check of cbc,
bun/cr, LFTs drawn ___ and results sent to primary MD as
surveillance mid-therapy. This was ordered by me through the
home infusion company, discussed with pt. and home infusion RN
over at bedside, and I also called primary care MD office and
informed them of this.
Surveillance cultures negative/no growth.
Called ___ -they had not drawn any cultures prior
to transferring pt here.
# Coagulopathy: On coumadin for Afib. S/p 5 mg IV vitamin K for
reversal given plan for ERCP, management as above.
# Relative thrombocytopenia. Likely due to infection/sepsis.
Improving now and throughout hospitalization here. Will get
repeat CBC, arranged for ___ as above.
# AFib: On home Atenolol and dronaderone. continued. Warfarin
held as above, until ___ given sphincterotomy. Chads-2
score is 2 (age/htn). Bridging therapy back to therapeutic
range not indicated based on BRIDGE trial.
# HTN: Antihypertensives transiently held during hospitalization
given npo status, infection, ___, except atenolol.
Can resume at discharge.
# GERD: Continued home famotidine.
# Anxiety: continued home alprazolam. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Indocin / Clinoril / naproxyn / allopurinol / sodium thiosulfate
/ probenecide / suldinac / indomethacine / Heparin Agents
Attending: ___.
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
___ year old male with h/o Crohn's disease, psoriasis and
psoriatic arthritis, who presents with rectal bleeding.
He was recently admitted ___ to ___ with hypotension and
diarrhea felt to be secondary to Crohn's flare. At that time he
was admitted to the MICU and improved with steroids and
antibiotics. He was found to have new Crohn's activity in his
terminal ileum and was continued on oral steroids. Also
completed a course of cipro/flagyl. Course complicated by
possible HIT and he was started on fondaparinux with some mild
bloody stools which had resolved at the time of discharge.
Discharged to rehab ___.
Per rehab notes, he developed loose stools that were grossly
bloody after arrival. Hct on admission there was 23, and
decreased to ___. Given 2 units PRBCs yesterday. Also had
BLE doppler which was negative for peripheral edema.
Fondaparinux has been held for the last several days. Seen by
GI at ___ who recommended consideration of biologic agent
for Crohn's but deferred to his GI providers.
The patient reports rectal bleeding for the past several days,
which he describes as a large amount of bleeding that resembles
the tomato sauce used when making a pizza. Endorses ___
episodes daily for the last several days, although denies
worsening of his diarrhea. Denies dizziness, chest pain, or
SOB. Does have constant abdominal cramping that is unchanged
since his discharge but no abdominal pain. Mild nausea at
times, buut no vomiting. Denies fevers.
In the ED, initial vitals were 98 70 112/70 18 97%RA. He was
guaiac negative in the ED. Most recent vitals 97.5 68 16 136/70
100%RA
Currently, he only complains of feeling nervous about the
bleeding episodes. No other complaints.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, nausea, vomiting, diarrhea, constipation,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Crohn's disease on mesalamine
-Psoriasis
-Psoriatic arthritis
-Hypertension
-GERD
-Hyperuricemia
-Anxiety
-Cholelithiasis
-Multiple liver hypodensities seen on CT, most likely cysts
-Left renal cyst
-Impaired glucose tolerance
-Ascending colon adenoma, removed (___)
-Obesity
Social History:
___
Family History:
Dad ___
Mom ___, brain aneurysms
Sister-CLL, ___ disease
Physical Exam:
ADMIT:
Vitals - 97.5 124/67 64 18 18 99%RA 102.5kg
GENERAL: Pleasant, well appearing male in NAD, slightly poor
historian
HEENT: Normocephalic, atraumatic, multiple bruises. No
conjunctival pallor. No scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Massive ___ pitting edema to abdomen with chronic
skin changes and some weeping. Multiple ecchymoses.
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
D/C:
Vitals: 98.0 100/60 55 20 96 RA
GENERAL: Pleasant, well appearing male in NAD, slightly poor
historian
HEENT: Normocephalic, atraumatic, multiple bruises. No
conjunctival pallor. No scleral icterus. Oral thrush
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: ___ ___ pitting edema to abdomen with chronic skin
changes Multiple ecchymoses.
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
___ 05:46PM LACTATE-1.3
___ 05:25PM URINE HOURS-RANDOM
___ 05:25PM URINE GR HOLD-HOLD
___ 05:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 05:25PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:25PM URINE MUCOUS-RARE
___ 05:20PM GLUCOSE-107* UREA N-10 CREAT-0.6 SODIUM-140
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-26 ANION GAP-10
___ 05:20PM estGFR-Using this
___ 05:20PM cTropnT-<0.01
___ 05:20PM cTropnT-<0.01
___ 05:20PM WBC-4.7 RBC-2.86* HGB-8.9* HCT-26.4* MCV-92#
MCH-31.3 MCHC-33.9# RDW-20.5*
___ 05:20PM NEUTS-89.5* LYMPHS-8.4* MONOS-1.9* EOS-0
BASOS-0.1
___ 05:20PM PLT COUNT-103*
___ 05:20PM ___ PTT-29.3 ___
___: Colonoscopy
Impression: Diffuse erythema, congestion, friability and
superficial ulceration of the mucosa with some areas oozing
scant amounts of blood. The disease was more severe from the
rectum to mid-descending colon. The remainder of the descending
colon, transverse and ascending colon had patchy disease. This
is consistent with crohn's colitis.
Otherwise normal colonoscopy to cecum
Recommendations: No definitve source of bleeding was noted on
this colonoscopy. The bleeding may be from his multiple ulcers
noted throughout the colon related to his Crohn's disease.
Continue management per inpatient GI team recommendations
___ 20:57
SEROTONIN RELEASE ASSAY
Negative
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 6:21 ___
FINDINGS: Color Doppler ultrasound performed of the right upper
extremity. There is normal flow, augmentation and
compressibility of the right internal jugular, subclavian,
axillary, brachial, basilic and cephalic veins. There is no
evidence of DVT in the right upper extremity.
IMPRESSION: No evidence of DVT in the right upper extremity.
Medications on Admission:
Alprazolam 0.5mg po daily prn anxiety - changed to 0.25mg po bid
prn at rehab
Colchicine 0.6mg po daily - made PRN at rehab
Clobetasol 0.05% foam bid prn psoriasis
Mesalamine 0.375g 4 capsules po daily
Prednisone 40mg po daily
Omeprazole 20mg po bid
Cholecalciferol 400 units po daily
Calcium carbonate 500mg po daily
Nystatin 100,000 units 5ml po qid prn thrush
Miconazole poweder tid prn rash
Hydrocort 0.2% cream daily prn rash
NaCl flushes
Fondaparinux 7.5mg SC daily - held for several days per rehab
notes
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clobetasol 0.05 % Cream Sig: One (1) Appl Topical BID (2
times a day) as needed for rash.
3. Apriso 0.375 gram Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO daily ().
4. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 8 doses.
10. alprazolam 0.25 mg Tablet Sig: ___ Tablets PO BID (2 times a
day) as needed for anxiety.
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
12. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical DAILY
(Daily) as needed for rash.
13. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower GI Bleed
Lower Extremity Edema
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
AP CHEST, 11:35 P.M., ___
HISTORY: ___ man with Crohn's disease, flaring. Evaluate PIC line.
IMPRESSION: AP chest compared to ___ through ___:
Tip of the left PIC line is now in the mid to low SVC, previously in the
azygos vein. Left lower lobe atelectasis and small bilateral pleural
effusions left greater than right have decreased. Heart size is normal.
Thoracic aorta is generally large. No pneumothorax.
Radiology Report
INDICATION: ___ man with history of right axillary, subclavian DVT
related to PICC, found to have thrombocytopenia, placed on anticoagulation
which causes GI bleed, question interval change.
COMPARISON: Upper extremity venous ultrasound from ___.
FINDINGS: Color Doppler ultrasound performed of the right upper extremity.
There is normal flow, augmentation and compressibility of the right internal
jugular, subclavian, axillary, brachial, basilic and cephalic veins. There is
no evidence of DVT in the right upper extremity.
IMPRESSION: No evidence of DVT in the right upper extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS/TARRY STOOLS
Diagnosed with MELENA, REGIONAL ENTERITIS NOS
temperature: 98.0
heartrate: 70.0
resprate: 18.0
o2sat: 97.0
sbp: 112.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with h/o Crohn's disease, psoriasis and
psoriatic arthritis, who presents with rectal bleeding.
.
# Rectal bleeding/Crohn's disease: had bleeding at ___
requiring 2 units PRBCs, although Hct on admission here was at
his recent baseline. Likely related to his anticoagulation
started for possible heparin induced thrombocytopenia (HIT) plus
his ongoing Crohn's disease. Had colonoscopy on previous
admission c/w Crohn's. Overall hemodynamically stable. His
hematocrits were checked serially and no transfusions were
given. He had a repeat colonoscopy which revealed "no definitve
source of bleeding .... The bleeding may be from his multiple
ulcers noted throughout the colon related to his Crohn's
disease." Fondaparinaux was held and not restarted in the
setting of his seratonin release assay (SRA) coming back
NEGATIVE for HIT. He was continued on mesalamine and prednisone
and initiated on Bactrim for PCP ___. He will need
outpatient GI followup to address starting biologic therapy such
as TNF alpha inhibitors.
.
# HIT: per above, SRA negative and thus considered not to have
true heparin induced thrombocytopenia w/ thrombosis (HITT),
however consultation with hematology recommended keeping Heparin
listed as an allergy given that he may have autoantibodies to
heparin but does not need anticoagulation given his negative
SRA. He also does not need hematology followup unless further
issues arise.
.
# Psoriasis: continued clobetasol as needed. Will consider TNF
therapy as outpatient for both Crohn's as well as psoriatic
arthritis.
.
# Peripheral edema: Has peripheral edema but recently had
bilateral lower extremiy US at ___ prior to transfer to
___ which reportedly were negative for DVT. This is likely
related to poor nutritional status and low albumin. He needs
aggressive nutritional supplementation. Patient requested
pneumatic compression boots which helped decrease edema and
served as DVT prophylaxis given heparin allergy.
.
# Fatty liver: will need followup with outpatient GI given his
previous CT findings concerning for NAFLD.
.
# Wound care:
For cleft ulcer:
Cleanse wound with wound cleanser then pat dry
then place sacral Mepilex border
change every 3 days |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ephedrine / Epinephrine / Levaquin / Cephalexin /
Bactrim DS / Percocet / morphine / gabapentin / Lyrica /
metformin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
Chole tube placement
History of Present Illness:
___ h/o HTN, SVT, PVD from OSH for ERCP and who presents with
acute onset post-prandial RUQ pain. Patient states that she has
had intermittent right upper quadrant pain for the past few
weeks usually after meals. Yesterday evening, around 5:30 ___,
after she had a meal, the pain in her right upper quadrant
became quite severe and persistent, radiating to the back and up
the sternum, rated ___. The pain subsided significantly once
she was being transported by ambulance. She had nausea, but no
emesis, and she denies melena or bright red blood per rectum.
She went to OSH where a CT scan was performed with concern for
choledocholithiasis w/CBD dilitation. Patient was transferred
here for ERCP higher level of care. Patient endorses a recent
URI, but denies fever/chills, chest pain, dyspnea.
At OSH she received vanco, cefepime, Flagyl around 10 ___. Also
received 4L NS and had a central line placed due to hypotension
at OSH.
In the ED, VS: T 97.4 BP 106/55 HR 82 RR 18 SatO2 97%/RA
Notable labs:
Cl 112 Bicarb 21 BUN 28 Cr 1.3
LFTs: ALT 396 AST 735 AP 123 Tbili 1.7 Alb 2.9
[LFTs at ___: ALT 493 AST 1065 Tbili 1.4 AP
151]
Lactate 2.9 --> 3.8
VBG: pH 7.28
UA: WBC 12 Bact few Leuk mod
Given: Norepi drip, Duoneb
Imaging:
CT shows dilated CBD with possible distal stone
On arrival to the ICU, patient is hemodynamically stable,
complaining of mild RUQ pain on palpation.
Past Medical History:
PAST MEDICAL HISTORY:
Anxiety
Fibromyalgia
Cervical Radiculitis
Lumbar Radiculopathy L5,S1
Depression
GERD
Hyperlipdemia
Hypertension
Left Cartid Bruit
Migraine headaches
Nocturnal leg cramps
Peripheral Vascular Disease
Supraventricular arrythmia
Migraine Headaches
Osteoarthritis
Surgical History:
___ L2-L3, L3-L4, Re-do Laminotomies w/ L3-S1 Fusion & L3-4
instrumentation and removal of previous hardware
Lumbar Radiculopathy L5,S1
TAH/BSO at age ___
s/p benign breast duct removal in ___
s/p lipoma removal
"easy bleeding" - normal coags
s/p tonsillectomy/adenoidectomy
Social History:
___
Family History:
Family history of diabetes (paternal grandmother and sister).
Father had multiple myeloma, mother had CHF. Father's siblings
had pancreatic cancer, AML, ovarian cancer (old age of onset),
breast cancer (unknown age of onset). Sister with DM, afib.
Brother with PUD, arthritis.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.3 BP: 140/76 P: 92 R: 21 O2: 98%/RA
GENERAL: elderly woman, anxiously lying in bed in NAD. AOx3
HEENT: PERLA, anicteric sclera, clear oropharynx
NECK: supple, no LAD, difficult to appreciate JVD due to body
habitus
LUNGS: wheezing bilaterally ___ up lung fields, no crackles,
rhonci, or rales
CV: irregular rhythm, normal rate, S1 S2, no murmurs, rubs,
gallops
ABD: obese pannus, tender to palpation over RUQ, no rebound or
guarding
EXT: non-pitting ankle edema up to mid-shin bilaterally
PHYSICAL EXAM on DISCHARGE:
Vitals: T 97.4 BP 124/62 HR 84 RR 27 SatO2 97%/RA
GEN: NAD, AOx3
___: RR, no murmurs
LUNGS: crackles at bases
ABD: soft, non-distended, tender to palpation over RUQ
EXT: no leg edema
Pertinent Results:
ADMISSION LABS
___ 12:25AM BLOOD WBC-4.1 RBC-3.65* Hgb-11.4 Hct-35.2
MCV-96 MCH-31.2 MCHC-32.4 RDW-11.8 RDWSD-41.3 Plt ___
___ 12:25AM BLOOD ___ PTT-22.4* ___
___ 12:25AM BLOOD Glucose-212* UreaN-28* Creat-1.3* Na-141
K-4.1 Cl-112* HCO3-21* AnGap-12
___ 12:25AM BLOOD ALT-396* AST-735* LD(LDH)-683*
AlkPhos-123* TotBili-1.7*
___ 12:58AM BLOOD ___ pO2-34* pCO2-44 pH-7.28*
calTCO2-22 Base XS--6
___ 12:28AM BLOOD Lactate-2.9*
DISCHARGE LABS:
___ 04:00AM BLOOD WBC-4.8 RBC-2.87* Hgb-8.9* Hct-27.4*
MCV-96 MCH-31.0 MCHC-32.5 RDW-12.7 RDWSD-43.9 Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-137
K-3.6 Cl-107 HCO3-26 AnGap-8
___ 04:00AM BLOOD ALT-72* AST-21 AlkPhos-156* TotBili-1.0
___ 04:00AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.5*
___ 06:14PM BLOOD Type-ART FiO2-50 pO2-98 pCO2-38 pH-7.31*
calTCO2-20* Base XS--6 Comment-O2 DELIVER
___ 03:13AM BLOOD Lactate-1.8
STUDIES:
ECG (___):
Sinus rhythm. Occasional premature atrial contractions. Compared
to previous tracing no diagnostic change.
Chest XR (___):
Bibasilar opacities likely reflecting atelectasis but cannot
exclude
aspiration or pneumonia in the right clinical setting.
Chest XR (___):
Severe bibasilar atelectasis is new accounting for substantial
decrease in lung volumes since ___. Mild pulmonary edema is
probably present as well. Increased intravascular volume is
reflected in increased caliber the mediastinum. Heart size is
obscured by the elevated diaphragm.
Chest XR (___):
Pulmonary edema has resolved. Low lung volumes persist.
Bibasilar
atelectasis have markedly improved. Suspected small bilateral
effusions are larger on the right. No other interval changes.
Liver/gallbladder U/S with Dopplers (___):
Distended gallbladder with edematous wall thickening to 11 mm
and
pericholecystic fluid. Sludge and a possible conglomeration of
small stones in the gallbladder. Findings concerning for acute
cholecystitis.
ERCP (___):
Stone at the middle third of the common bile duct
Otherwise normal cholangiogram.
A sphincterotomy was performed.
The stone was extracted successfully using a balloon.
Small amout of sludge and pus was also extracted.
A biliary stent was placed successfully.
(sphincterotomy, stone extraction, stent placement)
Otherwise normal ercp to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 75 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO 1X/WEEK (FR)
4. Losartan Potassium 25 mg PO DAILY
5. Meclizine 12.5 mg PO Q6H:PRN prn
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Simvastatin 10 mg PO QPM
8. Spironolactone 25 mg PO DAILY
9. Lorazepam 0.5 mg PO Q8H:PRN anxiety
10. Duloxetine 90 mg PO DAILY
Discharge Medications:
1. BuPROPion 75 mg PO DAILY
2. Duloxetine 90 mg PO DAILY
3. Lorazepam 0.5 mg PO Q8H:PRN anxiety
4. Losartan Potassium 25 mg PO DAILY
5. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
6. Meclizine 12.5 mg PO Q6H:PRN prn
7. CefTAZidime 2 g IV Q12H
IF ON HD, administer dose on the ward after patient returns from
each hemodialysis session.
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Benzonatate 100 mg PO TID
10. Bisacodyl 10 mg PO DAILY
hold for loose stools
11. Heparin 5000 UNIT SC TID
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 8.6 mg PO BID
14. Aspirin 81 mg PO DAILY
15. Hydroxychloroquine Sulfate 200 mg PO 1X/WEEK (FR)
16. Metoprolol Succinate XL 100 mg PO DAILY
17. Simvastatin 10 mg PO QPM
18. Spironolactone 25 mg PO DAILY
19. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: History: ___ with sob // ? pulmonary edema
TECHNIQUE: Single AP view of the chest.
COMPARISON: Comparison made chest radiographs from ___ and ___.
FINDINGS:
Lung volumes are low. Opacities are seen in the bilateral lung bases likely
reflecting atelectasis but cannot exclude aspiration or pneumonia in the right
clinical setting. There is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is unremarkable.
IMPRESSION:
Bibasilar opacities likely reflecting atelectasis but cannot exclude
aspiration or pneumonia in the right clinical setting.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: History: ___ with cholangitis, ?CBD stone per osh but would like
formal U/S STAT // cbd stone?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Comparison is made with OSH CT abdomen from ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: The gallbladder is distended and the wall is edematous and
thickened to 11 mm. There is pericholecystic fluid. Sludge and a possible
conglomeration of small stones is seen in the gallbladder. Findings are
concerning for acute cholecystitis.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
KIDNEYS: Limited views of the right kidney are unremarkable.
IMPRESSION:
Distended gallbladder with edematous wall thickening to 11 mm and
pericholecystic fluid. Sludge and a possible conglomeration of small stones
in the gallbladder. Findings concerning for acute cholecystitis.
NOTIFICATION: Findings communicated to Dr. ___ at 3:50 a.m. on ___.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement
INDICATION: ___ year old woman with acute on chronic cholecystitis // perc.
chole tube
COMPARISON: Gallbladder ultrasound ___, outside CT abdomen ___
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___ 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 supine position on the ultrasound table. Limited
pre-procedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, 18G ___ needle was inserted into
the collection. 0.038 ___ wire was placed through the needle and needle
was removed. A sample of fluid was aspirated, confirming needle position
within the collection. This was followed by placement of ___ Exodus
catheter into the collection. The stiffener and the wire were removed.
Pigtail was deployed, and the position of the pigtail was confirmed within the
collection via ultrasound.
Approximately 70 cc of brown fluid was drained 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.
SEDATION: Moderate sedation was provided by administering divided doses of
0.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
60 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Initial ultrasound demonstrates a fluid filled gallbladder which also
demonstrated some sludge. Post drain placement, there was minimal residual
fluid in the gallbladder. No immediate postprocedure complication.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with abd pain s/p perc chole tube placement //
eval for free air. ERECT KUB
TECHNIQUE: Portable supine abdominal radiographs were obtained.
COMPARISON: CT abdomen from outside hospital dated ___.
FINDINGS:
There is a percutaneous cholecystostomy tube overlying the right upper
quadrant. There is a femoral catheter overlying the left pelvis.
There is mild dilation of the transverse colon measuring up to 6.7 cm. There
are no dilated loops of small bowel. There is air seen within the rectum.
There is no evidence of intraperitoneal free air, although exam limited by
supine technique. There are degenerative changes of the lumbar spine status
post laminectomy with L4-L5 fusion hardware visualized.
IMPRESSION:
1. No evidence for pneumoperitoneum, however exam limited by supine
technique. Recommend upright or left lateral decubitus views if
pneumoperitoneum remains a clinical concern.
2. Percutaneous cholecystostomy which appears in appropriate position.
3. Non-obstructive bowel gas pattern.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
CLINICAL HISTORY ___ year old woman with perc chole // eval free air
eval free air
COMPARISON: ___
FINDINGS:
An area of increased density at the right lung base persists. There is
bibasilar subsegmental atelectasis as well. Lung volumes are low. The left
hemidiaphragm is elevated. There is no free air beneath the diaphragm.
Mediastinal structures are stable. A radiopaque catheter is projected over
the right abdomen.
IMPRESSION:
No free air is identified. No significant change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory distress. // Evaluate for
interval change. Evaluate for interval change.
COMPARISON: Prior chest radiographs since ___ most recently ___.
IMPRESSION:
Severe bibasilar atelectasis is new accounting for substantial decrease in
lung volumes since ___. Mild pulmonary edema is probably present as well.
Increased intravascular volume is reflected in increased caliber the
mediastinum. Heart size is obscured by the elevated diaphragm
RECOMMENDATION(S): .
NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on
___ at 4:37 ___, minutes after discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with need for central access. // Please read
for 35cm right basilic PICC.Thanks! ___ ___ Contact name: ___,
___: ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 5 hours earlier
IMPRESSION:
Right PICC tip is in thelower SVC. There are no other interval changes. .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman admitted with cholecystitis and septic shock
s/p drain placement and ERCP with pulmonary flash edema yesterday. // fluid
overload? volume status?
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed ___ at 18 hours
IMPRESSION:
Pulmonary edema has resolved. Low lung volumes persist. Bibasilar
atelectasis have markedly improved. Suspected small bilateral effusions are
larger on the right. No other interval changes
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with CHOLANGITIS, HYPOTENSION NOS
temperature: 97.4
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 106.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ has a history of HTN, SVT, and PVD and she presented
to ___ with acute onset post-prandial RUQ pain, found to
have choledocholithiasis on CT scan, and transferred to ___
for ERCP. In ERCP, one stone was removed from the CBD with small
amount of sludge and pus.
1. Choledocholithiasis: Now s/p ERCP with stone removal and perc
chole tube placement. Currently on Ceftazidime and flagyl for 7
day course THROUGH ___. Plan for perc chole tube removal and
repeat ERCP in 6 weeks.
2. Hypotension/septic shock: Patient presented to OSH with
hypotension, requiring pressors (levophed). Antibiotic course
initially broadened to vancomycin in addition to ceftazidime and
flagyl. Once source control was achieved her hemodynamics
improved and she was weaned off levophed.
3. Flash pulmonary edema: Hospital course complicated by flash
pulmonary edema requiring BIPAP and diuresis. Occured in the
setting of anxiety and hypertension as well as 5L volume
resuscitation for sepsis. Resolved with BiPAP, 20 IV lasix x2.
Anxiety medications restarted. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
Transthoracic T6, T7 corpectomy.
Posterior Fusion T7-T9
History of Present Illness:
___ with history of cardiomyopathy presenting with 2 month
history of upper back pain with acute worsening and found to
have
epidural abscess. Patient reports 2 month history of atraumatic
back pain worsening over the past 2 weeks. Initially had x-ray
on
___ which showed mild anterior wedging of T7 vertebral body.
Had
repeat x-ray on ___ which showed question of infectious process
at T6-T7 intervetebral disc space. MRI obtained today which
showed epidural and paraspinal abscesses at T6/T7. No f/c. No
weakness or numbness in any of his extremities. No bowel/bladder
incontinence.
Past Medical History:
mild cardiomyopathy
peripheral neuropathy
Social History:
___
Family History:
Non contributory
Physical Exam:
Vitals: 98.2 84 149/86 16 94%
General: NAD
Mental Status: AAOx3
Cranial nerves II-XII grossly intact.
Vascular
Radial UlnarFem Pop DP ___
R ___ ___
L ___ ___
Sensory:
___
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
Rintact intact intact intact intact
Lintact intact intact intact intact
T2-L1 (Trunk) intact
___ L2 L3 L4 L5S1S2
(Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
Rintactintactintactintact intactintact
Lintact intactintactintact intactintact
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 5 5 5 5 ___
L 5 5 5 5 ___
___ Flex(L1)Add(L2)
___
R ___ 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5)BR(C5-6)Tri(C6-7)Pat(L3-4)Ach(L5-S1)
R 2 2 2 2 2
L 2 2 2 2 2
Babinski: down BIL
Clonus: negative
Pertinent Results:
___ 06:20AM BLOOD WBC-8.7 RBC-3.12* Hgb-9.4* Hct-27.9*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.2 Plt ___
___ 05:19AM BLOOD WBC-7.9 RBC-2.89* Hgb-8.7* Hct-25.6*
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.9 Plt ___
___ 05:33AM BLOOD WBC-10.2 RBC-2.81* Hgb-8.6* Hct-25.3*
MCV-90 MCH-30.5 MCHC-33.9 RDW-14.1 Plt ___
___ 02:39AM BLOOD WBC-10.1 RBC-2.82* Hgb-8.4* Hct-25.1*
MCV-89 MCH-29.9 MCHC-33.6 RDW-14.1 Plt ___
___ 06:59AM BLOOD WBC-14.5* RBC-3.51* Hgb-10.5* Hct-31.3*
MCV-89 MCH-29.9 MCHC-33.5 RDW-13.9 Plt ___
___ 01:53AM BLOOD WBC-12.8* RBC-3.35* Hgb-10.2* Hct-30.2*
MCV-90 MCH-30.5 MCHC-33.8 RDW-13.8 Plt ___
___ 08:41PM BLOOD WBC-17.8*# RBC-3.60* Hgb-11.0* Hct-32.7*
MCV-91 MCH-30.6 MCHC-33.8 RDW-14.0 Plt ___
___ 2:30 pm TISSUE T6-T7 TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ (___) ___
AT 1049.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSI REQUESTED BY ___ ___ ___.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED
___. ___ ___ Male ___
___
Report to: ___. ___
___ by: ___. ___
SPECIMEN SUBMITTED: T6-T7, left lung nodule.
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
DIAGNOSIS:
I. Bone, T6-T7 (A-B):
Bone with acute and chronic osteomyelitis and remodeling.
II. Left lung nodule (C):
Infarcted adipose tissue.
Clinical: T6-T7 epidural abscess.
___: The specimen is received fresh in one container labeled
with the patient's name ___", the medical record
number and additionally labeled "T6-T7 bone". It consists of
multiple fragments of firm, white hemorrhagic bone that measure
3.5 x 2 x 0.5 cm in aggregate. The bony fragments appear
grossly unremarkable and are entirely submitted in cassettes
A-B, following decalcification.
Part 2 is additionally labeled "left lung nodule." It consists
of one fragment of firm white tissue that measures 1.2 x 0.9 x
0.7 cm. The outer surface of the tissue is inked in black. The
specimen is bisected to reveal solid pink yellow and lobulated
cut surfaces. The bisected nodule is entirely submitted in
cassette C.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Valsartan 40 mg PO BID
___ of 80mg Tab
2. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Valsartan 40 mg PO BID
___ of 80mg Tab
2. 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.
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *Dilaudid 2 mg ___ Tablet(s) by mouth every four (4) hours as
needed Disp #*80 Tablet Refills:*0
4. Docusate Sodium 200 mg PO BID
RX *Colace 100 mg 2 Capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
5. Nafcillin 2 g IV Q4H
6. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. T6-T7 pathologic fracture.
2. Kyphosis.
3. Thoracic stenosis.
Discharge Condition:
Good condition
Alert and oriented to person, place and time
Ambulating with assistance
Followup Instructions:
___
Radiology Report
STUDY: Lumbar spine intraoperative study ___.
CLINICAL HISTORY: Patient with T4 to T9 spinal fusion.
FINDINGS: Multiple images of the lumbar spine from the operating room
demonstrate placement of pedicle screws at T4, T5, T8 and T9. There are disc
prostheses at T5-T6, T6-T7, and T7-T8. No hardware-related complications are
seen. Paraspinal rods are then seen on the final images. There are stable
compression deformities at T6-T7. Please refer to the operative note for
additional details.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Left-sided chest tube is in place, with an apparent moderate-sized
left basilar pneumothorax, manifested by hyperlucency in the left upper
quadrant of the abdomen and a slightly deep costophrenic sulcus. The patient
is markedly rotated towards the right, limiting assessment for mediastinal
shift. Endotracheal tube tip terminates approximately 6 cm above the carina,
left internal jugular vascular catheter tip terminates in the region of the
junction of the left brachiocephalic vein and superior vena cava, and a
nasogastric tube courses below the diaphragm. Allowing for rotation,
cardiomediastinal contours are stable in appearance, with a markedly tortuous
and potentially dilated descending thoracic aorta. Bibasilar areas of
atelectasis are present as well as a possible layering right pleural effusion.
Subcutaneous emphysema is present in the left chest wall.
IMPRESSION: Moderate left basilar pneumothorax with left chest tube in place.
Dr. ___ has been telephoned with this result on ___ at 8:00
a.m., at the time of discovery of this finding.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ chest x-ray.
FINDINGS: Left chest tube remains in place. Previously reported basilar
pneumothorax is less well visualized, possibly due to positional differences
between the exams. Indwelling support and monitoring devices are unchanged in
position, and cardiomediastinal contours are stable. Improved aeration at the
left lung base with near resolution of linear left basilar atelectasis.
Slight worsening of atelectasis at the right lung base.
Radiology Report
PORTABLE AP CHEST FILM ___ AT 5:10 A.M.
CLINICAL INDICATION: ___ with spinal surgery, chest tube placement,
now desaturation. Evaluate for an acute respiratory process.
Comparison is made to the patient's prior study dated ___ at 8:23.
A portable semi-erect chest film ___ at 5:10 a.m. is submitted.
IMPRESSION:
1. The left chest tube is unchanged in position. A catheter overlying the
right mid chest and coursing towards the midline is unchanged in position.
The patient is markedly rotated and the aorta is unfolded and tortuous. There
is overall improved aeration of the left lung; however, there is increase in
opacification at the right base which likely reflects an worsensing
atelectasis and/or effusion. No pneumothorax. Spinal hardware overlies the
thoracic spine. There are also surgical skin staples. The left internal
jugular central line has its tip in the proximal SVC, unchanged. Interval
removal of a nasogastric tube.
Radiology Report
PORTABLE CHEST FILM, ___ AT 11:24
CLINICAL INDICATION: ___ with hypoxia status post spine fusion.
Evaluate for interval change.
Comparison is made to the patient's previous study dated ___ at 5:10
a.m.
Single portable upright chest film, ___ at 11:24 is submitted.
IMPRESSION:
Left internal jugular central line tip in the proximal SVC. A left chest tube
remains in place. No pneumothorax is appreciated. There is improved
aeration, particularly at the right base suggesting that the previously seen
opacity more likely corresponded to partial lower lobe atelectasis rther than
pneumonia. A small component of layering pleural fluid cannot be entirely
excluded. The left lung is grossly clear. Aorta is somewhat unfolded and
tortuous. The heart is mildly but stably enlarged. No evidence of pulmonary
edema. No definite pneumothorax is seen. Spinal hardware overlies the
thoracic spine where there are also surgical skin staples consistent with
recent surgery.
Radiology Report
PORTABLE CHEST FROM ___ AT 12:18
CLINICAL INDICATION: ___ status post chest tube removal, evaluate for
pneumothorax.
Comparison is made to the patient's prior study of ___ at 11:24.
Portable semi-erect chest film, ___ at 12:18 is submitted.
IMPRESSION:
Interval removal of the left chest tube with a probable very tiny left apical
pneumothorax. The patient's nurse, ___, was notified by phone on ___
at 2:02pm. The visualized lungs are grossly clear, although there are some
patchy streaky opacities at the left base as well as some patchy opacity at
the right base which may reflect patchy atelectasis. Overall, cardiac and
mediastinal contours are difficult to assess due to marked patient rotation on
the current examination. Spinal hardware overlies the thoracic spine with
some adjacent surgical skin staples consistent with recent surgery. Left
internal jugular central line unchanged in position. Catheter overlying the
right mid to lower chest is unchanged.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: The patient is status post recent spinal surgery with spinal
hardware unchanged in position. Cardiomediastinal contours are stable in
appearance. Persistent bilateral pleural effusions and slight improvement in
degree of bibasilar atelectasis.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: Patient with placement of PICC line.
FINDINGS: Comparison is made to prior study from ___.
There has been placement of a right-sided PICC line whose distal lead tip is
in the superior SVC. This could be advanced 5 cm for more optimal placement.
There is a left IJ central venous line with distal lead tip at the cavoatrial
junction. There is a thoracic spinal hardware which partially limits
evaluation of mediastinum. Surgical skin staples are also seen projecting
over the central midline. There is marked tortuosity of thoracic aorta.
There is some atelectasis at the lung bases. There are no pneumothoraces or
signs for overt pulmonary edema.
Radiology Report
STUDY: Thoracic spine, ___.
CLINICAL HISTORY: ___ man with T4-T9 posterior spinal fusion, status
post readjustment of PICC line.
FINDINGS: Comparison is made to the prior study from ___ at 11:37
a.m.
There is again seen a right-sided PICC line whose distal tip is within the
proximal SVC. There is a loop in the distal portion of the catheter best seen
on the lateral view. The catheter is partially obscured by the spinal
hardware on the AP: view. There is a left IJ central line with distal lead
tip in the distal SVC. The cardiac silhouette is within normal limits. There
is tortuosity of the thoracic aorta. There are no pneumothoraces. There is
extensive spinal hardware spanning T4-T9. Surgical skin staples are seen
posteriorly.
IMPRESSION: There is a loop in the distal portion of the PICC line and the
tip remains in the proximal SVC. Discussed with the PICC nurse.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement.
COMPARISON: ___, 10:12 a.m.
FINDINGS: As compared to the previous radiograph, the guidewire has been
removed. The tip of the PICC line is not clearly visualized as the line is
partly obscured by spinal hardware. Very likely, the tip projects over the
confluence of the superior vena cava and the brachiocephalic vein, which is
slightly too high. However, a lateral radiograph should be able to clarify
the line position.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New right PICC line. Evaluation.
COMPARISON: ___, 1137.
FINDINGS: A lateral radiograph only is provided. The tip of the PICC line is
not displayed on the lateral radiograph. On this basis, the suspicion must be
raised that the tip of the line is too proximal, approximately at the junction
of the superior vena cava and the brachiocephalic vein. Advancement of the
line should be considered.
Radiology Report
PICC LINE EXCHANGE / REPOSITIONING
INDICATION: Malposition of indwelling PICC line.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ Dr. ___ the procedure. Dr ___ was
present in the room for the entire procedure.
TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was
advanced through the indwelling basilic arm PICC line, and subsequently into
the SVC under fluoroscopic guidance. The old PICC line was then removed and a
peel-away sheath was then placed over the guidewire. A new single-lumen PICC
line measuring 55 cm in length was then placed through the peel-away sheath
with its tip positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a
new right basilic single-lumen PICC line. Final internal length is 55 cm,
with the tip positioned in the SVC. The line is ready to use.
Radiology Report
STUDY: Left hand, ___.
CLINICAL HISTORY: Patient with swollen, edematous left thumb. Evaluate for
fracture.
FINDINGS: There are severe degenerative changes of the first CMC joint with
prominent spurs, joint space narrowing and subchondral sclerosis. Mild
degenerative changes of the triscaphe and second MCP joint are seen. There is
also radiocarpal joint space narrowing as well as mid carpal row narrowing.
Degenerative changes of the distal radioulnar joint is also identified.
Several of the DIP and PIP joints also demonstrate degenerative changes, worst
of the small and index finger. There are no signs for acute fractures.
IMPRESSION:
1. Severe degenerative changes as described above, worst within the first CMC
joint.
2. No definite fractures.
Radiology Report
INDICATION: ___ male with T6-7 epidural abscess, evaluate for bony
abnormality.
COMPARISONS: MRI of the spine from ___ obtained of the same day.
TECHNIQUE: MDCT axial images were obtained through thoracic spine without the
administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed.
FINDINGS: Noted at the T6-T7 level is endplate destruction and obliteration
of the disc space with an associated soft tissue mass. This is better
characterized on the MRI of the same day. Although the alignment is overall
maintained there is kyphotic angulation at this level.
There are mild degenerative changes of the thoracic spine. There are
bilateral small pleural effusions. Bilateral consolidations compatible with
atelectasis and aspiration are noted. Debris is seen within the bronchus
intermedius. There is no pneumothorax. Although this exam was not tailored
to evaluate the intra-abdominal contents, the visualized portions of the
kidneys, adrenal glands, liver and pancreas are normal.
IMPRESSION:
1. Discitis and osteomyelitis of T6-7 with an associated soft tissue mass
likely representing abscess, all better characterized on MRI obtained the same
day.
2. Bilateral small effusions and consolidations which are compatible with
atelectasis and aspiration pneumonitis with debris seen in the bronchus
intermedius.
Radiology Report
INDICATION: Patient with thoracic spine epidural abscess.
COMPARISONS: Thoracic spine CT of the same date.
FINDINGS: Frontal and lateral views of the chest demonstrate low lung volumes.
Bibasilar opacities are better assessed on CT exam of the same date. No
pneumothorax. Hilar and mediastinal silhouettes are unremarkable. The
ascending aorta appears tortuous. Heart size is normal. There is no
pulmonary edema. Acute kyphosis and disc obliteration at T6-7 level is better
assessed on the same day MRI.
Radiology Report
STUDY: Thoracic ___.
CLINICAL HISTORY: Patient with anterior T6-T7 corpectomy and T4-T9 spinal
fusion.
FINDINGS: Multiple images of the thoracic spine demonstrate wedging of the T6
and T7 vertebral bodies. There is subsequent placement of disc prosthesis at
three levels with improvement of the height. These are at the T5-T6, T6-T7
and T7-T8 levels. Please refer to the operative note for additional details.
The endotracheal tube is 7 cm above the carina, appropriately sited. There is
a nasogastric tube whose side port is at the GE junction and could be advanced
several centimeters for more optimal placement.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ?EPIDURAL ABSCESS
Diagnosed with CNS ABSCESS NOS, PRIM CARDIOMYOPATHY NEC
temperature: 98.2
heartrate: 84.0
resprate: 16.0
o2sat: 94.0
sbp: 149.0
dbp: 86.0
level of pain: 3
level of acuity: 3.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for a corpectomy and posterior
spinal fusion on ___. Refer to the dictated operative
note for further details. The surgery was without complication
and the patient was transferred to the ICU in a stable condition
due to his age and extent of surgery. Patient was continued on
an antibiotic regimen of vancomycin, ceftriaxone and flagyl. On
___ patient was extubated and a full neuro exam was performed
after sedation was weaned. Physical therapy was consulted for
mobilization OOB to ambulate. On ___ patient returned to the
SICU and was intubated for respiratory distress. He was
transferred back to the floor on ___, ceftriaxone and flagyl
were stopped per recommendations from Infectious Disease. ___ a
PICC line was ordered for long term antibiotic therapy, patient
was noted to hvae PVCs and LBBB but was asymptomatic, home
cardiac medicines were investigated and restarted. ___ Vanco
trough was within goal range at 15.4, PICC line was placed but
was found and was replaced on ___ final ID recs antibiotic
changed from vancomycin to naficillin. On ___ patient developed
a swollen, erythematous MCP joing of the thumb on the left hand,
uric acid came back within normal limits and an x-ray of the
left hand showed only arthritic changes in the MCP joint. On ___
swelling and erythema of the left thumb had resolved
significantl. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet. Patient was discharged to an
___ rehab facility, his expected stay is less than 30
days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
MRI showing strokes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old right handed man who was recently admitted at
___ in ___ for an NSTEMI/ respiratory distress with a
complicated course of delirium and pneumonia who returns today
after MRI findings of multiple areas of restricted diffusion
concerning for strokes. On prior admission he was initially
planned for a CABG but this did not occur secondary to his
delirium placing him at a high mortality risk. Eventually he had
a stent to RCA, angioplasty of the LCx. Was also aggressively
diuresed. Hospital stay was complicated with a ventilator
associated pneumonia and hypernatremia due to dehydration, acute
renal failure (pre renal), delirium, dysphagia (failed a swallow
eval). Neurology saw him during this hospitalization for his
confusion and was concerned for subclinical seizures. He was
discharged to the rehab but continued to have episodes of
agitation. He states that "I'm just difficult to deal with
because I don't like idiots." Either way he had an MRI of the
brain done on ___ and Multiple bilateral scattered
lesions
concerning for embolic infarction, in ant and post circulations.
When results reached his rehab he was transferred to ___ for
further evaluation. He states that he feels fine and that he
isn't really sure why the sent him here. Since being sent to
rehab he does say he has a chronic cough and some night sweats.
He has intermittent headaches. He still has not been allowed to
swallow although he says that he can and has had a foley in
since
discharge. He has generalized weakness and has yet been allowed
to walk "Because they are scared I'll fall."
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. No recent weight loss or gain. Denies shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
1. Diabetes
2. Dyslipidemia
3. Hypertension
4. CABG: none
5. Angioplasty x2 in ___
6. COPD
Social History:
___
Family History:
- Limited and obtained from OSH records.
- Mother: CAD
- Father: brain cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T:98.8 P:84 R: 18 BP:148/63 SaO2:98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple,
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes, and ___ with
semantic cues. The pt. had good knowledge of current events.
There was no evidence of apraxia or neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. Extra skin
folded over the left eye but no ptosis
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: mild parietal drift bilaterally. high frequency low amp
postural tremor and left sided action tremor.
Delt Bic Tri WrE IP Quad Ham TA ___
L 5 ___ 4 4+ 5- 3 5- 4 3
R 5 ___ 4 4+ 5- 3 5- 4 3
.
-Sensory:stocking gradient to pinprick, proprioception intact to
ankles. No extinction to DSS.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
.
-Coordination: + intention tremor. No dysmetria on HKS
bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2, 161/79, 80, 20, 96% on RA
GEN: sitting in bed in NAD
HEENT: NGT in place, OP clear
CV: irreg irreg
PULM: CTAB
ABD: soft, NT, ND
EXT: no edema
NEURO EXAM:
MS - AAOx2 (didn't know date), speech fluent
CN - EOMI, PERRL 3->2, face symmetrical, tongue midline
MOTOR - ___ throughout
SENSORY - intact to light touch throughout
GAIT - deferred.
Pertinent Results:
ADMISSION LABS:
___ 08:04PM BLOOD WBC-10.7 RBC-3.88*# Hgb-12.4*# Hct-37.4*
MCV-96 MCH-32.1* MCHC-33.3 RDW-14.9 Plt ___
___ 08:04PM BLOOD Neuts-70.5* Lymphs-15.6* Monos-8.8
Eos-4.7* Baso-0.5
___ 08:04PM BLOOD ___
___ 08:04PM BLOOD Glucose-189* UreaN-22* Creat-0.8 Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
___ 08:04PM BLOOD ALT-20 AST-20 LD(LDH)-169 AlkPhos-91
TotBili-0.2
___ 08:04PM BLOOD cTropnT-0.02*
___ 08:04PM BLOOD Albumin-3.7 Calcium-9.6 Phos-4.5 Mg-2.1
___ 08:04PM BLOOD VitB12-939*
___ 08:04PM BLOOD TSH-1.3
___ 08:04PM BLOOD CRP-3.9
___ 08:04PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 05:20AM BLOOD WBC-16.8*# RBC-3.99* Hgb-12.6* Hct-38.3*
MCV-96 MCH-31.6 MCHC-33.0 RDW-14.9 Plt ___
___ 05:20AM BLOOD Glucose-121* UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
___ 05:20AM BLOOD CK(CPK)-43*
___ 05:20AM BLOOD CK-MB-2 cTropnT-0.03*
REPORTS:
CXR ___: IMPRESSION: Patchy new opacities in the right mid
and left lower lungs, more suggestive of atelectasis than
pneumonia. However, it may be appropriate to perform short-term
follow-up radiograph to show that these resolved, particularly
if there is any clinical concern for the possibility of
pneumonia.
MR HEAD ___ IMPRESSION: Expected evolution of scattered
small foci of slow diffusion in both hemispheres, likely embolic
infarcts, without evidence of new focus or acute territorial
infarction.
CXR ___: IMPRESSION: New posterior basal segment right
lower lobe opacity concerning for pneumonia or aspiration.
Persistent focal posterior segment right upper lobe opacity
could reflect recurrent aspiration/infection, but follow up
chest radiographs would be helpful to document resolution in
order to exclude either a chronic infection
or a neoplasm mimicking infection.
VIDEO SWALLOW ___: IMPRESSION: Trace penetration with thin
liquids, no aspiration.
Medications on Admission:
-albuterol sulfate neb 2.5 mg QID
-aspirin 325 mg daily
-carvedilol 12.5 mg BID
-clopidogrel 75 mg daily
-furosemide 20 mg daily
-heparin 5000 units q8 hours
-hydralazine 25 mg QID
-Insulin Lantus 19 units
-Ipratropium BR 0.5 mg QID neb
-Isosorbide 60 mg daily
-Lisinopril 20 mg daily
-Multivitamin daily
-quetiapine 25 mg TID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aspirin 325 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Heparin 5000 UNIT SC TID
7. Glargine 19 Units Bedtime
8. Ipratropium Bromide Neb 1 NEB IH Q6H
9. Lisinopril 20 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Quetiapine Fumarate 25 mg PO TID
12. HydrALAzine 25 mg PO Q6H
13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
14. Atorvastatin 80 mg PO DAILY
15. Cefpodoxime Proxetil 400 mg PO Q12H
Last dose ___ to complete a ___ischarge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multiple small embolic appearing infarcts
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO EXAM: inattentive, AAOx2 (doesn't know date or year)
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Recent embolic stroke with intermittent chest pain.
COMPARISONS: Chest radiographs from ___ and CT from ___.
TECHNIQUE: Chest, AP upright and lateral.
FINDINGS: The orientation of the AP film is lordotic. A nasogastric tube
courses into the stomach, its distal course not visualized. The heart is at
the upper limits of normal size with a left ventricular configuration. The
mediastinal and hilar contours appear unchanged. There is new patchy
opacification in the superior segment of the right lower lobe and also patchy
new lingular opacification. On the lateral view only are vague posterior
opacities that are hard to assess on the frontal view, but are probably within
the left lower lobe in the retrocardiac region. On the prior CT there was
substantial opacification in both posterior lower lobes, particularly the
left; the posterior left lower lobe finding may be due to residual atelectasis
or scarring, probably unchanged since the most recent of the prior radiographs
from ___.
IMPRESSION: Patchy new opacities in the right mid and left lower lungs, more
suggestive of atelectasis than pneumonia. However, it may be appropriate to
perform short-term follow-up radiograph to show that these resolved,
particularly if there is any clinical concern for the possibility of
pneumonia.
Radiology Report
INDICATION: ___ man with MRI evidence of new embolic strokes,
bilaterally. Assess for source of emboli.
COMPARISON: MR head dated ___.
TECHNIQUE: CTA of the head and neck was obtained with and without contrast
according to the department protocol.
FINDINGS:
CT HEAD: The cerebral sulci, ventricles, and extra-axial CSF spaces are
diffusely enlarged, reflecting global cerebral volume loss. The gray-white
matter differentiation is preserved and there is no CT evidence of territorial
infarct. As expected, recently reported scattered diffusion abnormalities are
not resolved by the CT technique. Extensive periventricular and deep white
matter low attenuation is in keeping with sequelae of chronic small vessel
ischemic disease. No intra- or extra-axial hemorrhage is identified. The
visualized paranasal sinuses and mastoid air cells are clear.
CTA HEAD: There is atherosclerotic disease with extensive calcified plaque
and vessel wall irregularity involving the bilateral cavernous, clinoid, and
proximal ophthalmic segment ICA with about 50% stenosis of the right proximal
ophthalmic segment. The bilateral vertebral and the basilar artery are
diminutive, the last, terminating in the superior cerebellar arteries. The
bilateral PCAs demonstrate a fetal origin. The anterior, middle, and
posterior cerebral arteries demonstrate normal contrast opacification without
evidence of stenosis, occlusion, arteriovenous malformation, or aneurysm.
Opacification of the venous sinuses is unremarkable.
CTA NECK: While there is diffuse atherosclerotic disease involving the aortic
arch, ulcerated non-calcified plaque is seen along the brachiocephalic trunk
and at origin of the left common carotid artery, causing about 50% stenosis of
the ostium.
Mixed plaque involves both internal carotid artery origins. On the right, the
minimal luminal diameter (Dmin) of the proximal cervical ICA is 2.5 mm, and on
the left, 1.5 mm. The corresponding Dmin measurements for the distal cervical
ICA segments are 4 mm and 4.5 mm, respectively. The cervical portions of the
more distal internal carotid artery segments are otherwise unremarkable.
While the vertebral arteries are diminutive bilaterally, there is no evidence
of significant origin stenosis or relevant atherosclerotic disease along their
cervical course.
Multiple hypoattenuating lesions are seen in the bilateral thyroid lobes and
may be further assessed by ultrasound, on an elective basis.
Lymph nodes in the cervical levels and mediastinum are increased in number
and should be clinically correlated.
There is significant emphysema in the lung apices.
IMPRESSION:
1. While the recently reported scattered small foci of slow diffusion are
beyond the contrast/spatial resolution of CT, there is no evidence of new
vascular territorial infarction.
2. Diffuse atherosclerotic disease with ulcerated non-calcified plaques
involving both the brachiocephalic trunk as well as the ostium of the left
common carotid artery.
3. Atherosclerotic disease with mixed plaque involving the bilateral common
carotid bifurcations, causing approximately 40-50% diameter stenosis on the
right and 60-70% diameter on the left.
4. Bilateral calcified plaque along the cavernous, clinoid and supraclinoid
segments of the intracranial ICA, with about 50% tandem stenosis on the right.
5. Prominent cervical and mediastinal lymph nodes that should be clinically
correlated.
Radiology Report
HISTORY: ___ male with CHF.
COMPARISON: ___.
FINDINGS: The lungs are well expanded, with expansion of the retrosternal
clear space indicating emphysema as demonstrated on prior CT. There has been
interval improvement in pulmonary vascular congestion. There is new opacity
overlying the spine on the lateral view seen in the right cardiophrenic sulcus
on the frontal concerning for developing pneumonia or aspiration. There is no
effusion or pneumothorax. The cardiac silhouette remains normal in size, the
mediastinal contours are normal. A Dobbhoff tube tip projects over the
expected location of the gastric antrum. A focal perifissural parenchymal
opacity projects in the posterior segment of the right upper lobe abutting the
major fissure and was also present on a prior CT scan of ___.
IMPRESSION: New posterior basal segment right lower lobe opacity concerning
for pneumonia or aspiration.
Persistent focal posterior segment right upper lobe opacity could reflect
recurrent aspiration/infection, but follow up chest radiographs would be
helpful to document resolution in order to exclude either a chronic infection
or a neoplasm mimicking infection.
Radiology Report
INDICATION: ___ man with multiple areas of restricted diffusion on
___ [sic]; follow-up exam.
COMPARISON: MR ___ dated ___.
TECHNIQUE: Sagittal T1 and axial FLAIR, T2, gradient echo, and diffusion
weighted images with ADC map, were obtained without contrast.
FINDINGS: The previous multiple scattered foci of slow diffusion,
bilaterally, demonstrate expected evolution with signal reduction on the
"trace" DWI images. Some smaller foci, such as those in the right corona
radiata, along the lateral ventricular margin, are no longer identified, which
may be seen in the setting of transient ischemia. There is no new focus of
restricted diffusion, and no evidence of vascular territorial infarction.
Again, there is no evidence of hemorrhage, mass or mass effect. The
ventricles, cerebral sulci, and extra-axial CSF spaces are diffusely enlarged,
reflecting age-related global atrophy.
The right mastoid air cells are fluid-filled, raising concern for mastoiditis
of unknown chronicity. The visualized paranasal sinuses are clear.
IMPRESSION: Expected evolution of scattered small foci of slow diffusion in
both hemispheres, likely embolic infarcts, without evidence of new focus or
acute territorial infarction.
Radiology Report
INDICATION: ___ man with swallowing difficulties and aspiration.
COMPARISONS: Video oropharyngeal swallow from ___.
FINDINGS: Video swallow fluoroscopy was completed in conjunction with the
speech and swallow division. Multiple consistencies of barium were
administered. Barium passed freely through the oropharynx without evidence of
obstruction. There was trace penetration with thin liquids which cleared.
There is no evidence of aspiration.
IMPRESSION: Trace penetration with thin liquids, no aspiration. Please see
the official speech and swallow note in OMR for further details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, URIN TRACT INFECTION NOS, OTHER MALAISE AND FATIGUE
temperature: 98.8
heartrate: 84.0
resprate: 18.0
o2sat: 98.0
sbp: 148.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Mr ___ is a ___ year old right handed man who was recently
admitted at ___ in ___ for an NSTEMI/ respiratory distress
with a complicated course of delerium and pneumonia who returned
on this admission after MRI findings of multiple areas of
restricted diffusion concerning for strokes.
.
# Neuro: patient's repeat MRI showed no new infarcts and the
multiple small embolic infarcts were felt to be related to his
cath he had 1 month previously. He was continued on ASA/plavix
given his drug eluting stents, and he had vasculitis labs sent,
which are still pending currently.
# Cardiovascular: we continued pt's home BP/CHF med as he was at
least 3 days out from his strokes on admission. He was unable
to get an echo during his stay here, so we recommend that he
receive one as an outpatient.
# Urinary: pt had foley left in at ___ for extended
amount of time, so we decided to straight cath him every 6 hours
here.
# Infectious disease: U/A showed a UTI so he was started on
ceftriaxone. His UCx showed GNR's, with speciation pending, so
at discharge he was sent out on cefpodoxime 400mg Q12H to stop
___ for a planned 7 day course.
# FEN: he came in with a bridled NGT, but here our speech and
swallow team cleared him for thin liquids and soft solids. We
left the NGT in until calorie counts could be completed. He
will need further calorie evaluations at rehab as we weren't
able to fully determine his intake here. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o non-verbal M w/ALS presenting w/increased fatigue and
weakness per wife. Patient lives at home with wife who provides
all of his care. Today she was lifting him from bed when he
"flopped" from her arms and she called an ambulance for
assistance. Wife notes some complaints of cough with eating and
R shoulder pain (for about two months) but otherwise denies
fevers, chills, chest pain, SOB, cough, abdominal pain, nausea,
vomiting, blood in stools, melena, dysuria, or hematuria. Pt
minimally interactive. Will follow simple commands in ___.
In the ED, initial vitals were 98.2 75 95/66 16 96%. Labs were
stable. UA showed no evidence of infection. CXR showed no
definite acute cardiopulmonary process given relatively low lung
volumes. Rt. shoulder Xray showed no fracture or dislocation.
Vitals prior to transfer were: 98.2 66 111/64 16 95% RA. He is
being admitted for progressive ALS and placement at long term
care facility vs home hospice.
Past Medical History:
Frontotemporal Dementia
Amyotrophic Lateral Sclerosis
Diabetes Mellitus: ___ HbA1c 10.1
Thrombocytopenia
Hypertension
Hyperlipidemia
Gastroesophageal Reflux Disease
Benign Prostatic Hyperplasia
Social History:
___
Family History:
Father had HTN and DM.
Mother passed away after delivery.
Children are all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.5, 107/67, 65, 20, 96% RA
GEN Non-verbal. Somnolent but rousable, minimally responsive.
HEENT NCAT MMM EOMI sclera anicteric, OP clear. Intermittent
wet-sounding cough, but non-productive.
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, scarring on shins
bilaterally.
NEURO CNs2-12 intact, motor function grossly normal. Rt shoulder
range of motion intact.
SKIN no ulcers or lesions
LABS: reviewed, see below
DISCHARGE PHYSICAL EXAM
VSS
physical exam unchanged
Pertinent Results:
ADMISSION LABS
___ 07:00PM BLOOD WBC-5.9 RBC-4.43* Hgb-13.5* Hct-39.3*
MCV-89 MCH-30.5 MCHC-34.4 RDW-12.4 Plt ___
___ 07:00PM BLOOD Neuts-69 Bands-0 Lymphs-17* Monos-12*
Eos-2 Baso-0 ___ Myelos-0
___ 07:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:00PM BLOOD Plt Smr-LOW Plt ___
___ 07:00PM BLOOD Glucose-74 UreaN-23* Creat-0.9 Na-136
K-4.4 Cl-97 HCO3-31 AnGap-12
___ 07:00PM BLOOD ALT-17 AST-30 AlkPhos-53 TotBili-0.4
___ 07:00PM BLOOD Albumin-4.3
___ 01:00PM BLOOD %HbA1c-10.1* eAG-243*
___ 07:13PM BLOOD Glucose-71 K-3.8
DISCHARGE LABS
___ 06:00AM BLOOD WBC-5.7 RBC-4.47* Hgb-13.5* Hct-39.9*
MCV-89 MCH-30.3 MCHC-33.9 RDW-12.5 Plt ___
___ 06:00AM BLOOD Glucose-93 UreaN-20 Creat-1.0 Na-140
K-3.5 Cl-98 HCO3-35* AnGap-11
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.0
URINE
___ 09:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
PERTINENT STUDIES
THREE VIEWS OF THE RIGHT SHOULDER ___: There is no
fracture or dislocation. There is moderate sclerosis of the
glenohumeral joint. Included views of the right upper chest are
clear. No rib fractures are detected. IMPRESSION: No fracture
or dislocation.
CXR ___
AP and lateral views of the chest. The lungs are clear given
low lung volumes with secondary crowding of the bronchovascular
markings. There is no consolidation or effusion.
Cardiomediastinal silhouette is stable as are the osseous and
soft tissue structures.
IMPRESSION:
No definite acute cardiopulmonary process given relatively low
lung volumes.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 325-650 mg PO PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
Hold for SBP<90, HR<50
4. Atorvastatin 10 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ranitidine 300 mg PO QPM
7. Sertraline 100 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
Hold for SBP<90
9. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL DAILY
10. NPH 56 Units Breakfast
Insulin SC Sliding Scale using Humulin R Insulin
11. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h
SOB/Wheezing
12. Glycopyrrolate 1 mg PO Q4H:PRN secretions
Discharge Medications:
1. Acetaminophen 325-650 mg PO PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
Hold for SBP<90, HR<50
4. Atorvastatin 10 mg PO DAILY
5. Glycopyrrolate 1 mg PO Q4H:PRN secretions
6. Omeprazole 40 mg PO DAILY
7. NPH 56 Units Breakfast
Insulin SC Sliding Scale using Humulin R Insulin
8. Ranitidine 300 mg PO QPM
9. Sertraline 100 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
Hold for SBP<90
11. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL DAILY
12. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h
SOB/Wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
ALS
Secondary Diagnoses:
Hypertension
Diabetes
Cough
Depression
BPH
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Nonverbal at baseline.
Mental Status: Awake.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with ALS and progressive fatigue. Question
pneumonia.
COMPARISON: Chest x-ray from ___.
FINDINGS:
AP and lateral views of the chest. The lungs are clear given low lung volumes
with secondary crowding of the bronchovascular markings. There is no
consolidation or effusion. Cardiomediastinal silhouette is stable as are the
osseous and soft tissue structures.
IMPRESSION:
No definite acute cardiopulmonary process given relatively low lung volumes.
Radiology Report
INDICATION: Right shoulder injury.
COMPARISON: Chest CT available from ___.
THREE VIEWS OF THE RIGHT SHOULDER: There is no fracture or dislocation.
There is moderate sclerosis of the glenohumeral joint. Included views of the
right upper chest are clear. No rib fractures are detected.
IMPRESSION: No fracture or dislocation.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: FATIGUE
Diagnosed with AMYOTROPHIC SCLEROSIS, DIABETES UNCOMPL JUVEN, HYPERTENSION NOS
temperature: 98.2
heartrate: 75.0
resprate: 16.0
o2sat: 96.0
sbp: 95.0
dbp: 66.0
level of pain: nan
level of acuity: 3.0 | Mr. ___ is a ___ y/o male with advanced ALS, frontotemproal
dementia, poorly controlled DM, HTN, presenting with increasing
care requirements at home, cough and right shoulder pain.
ACTIVE ISSUES
# Frontotemporal dementia / ALS: Profound, non-verbal,
progressive. Pt's current presentation is unchanged from his
based line per discussion with pt's wife and son. There was a
concern of right arm pain from the family. A shoulder/arm X-ray
was performed, which did not reveal fractures.
# GOAL OF CARE DISCUSSION: When last seen by neuro, family
discussion was held regarding patient's increasing needs and
possible transition to care in a SNF. At the time, patient's
family were reluctant to pursue SNF placement, but care needs
have increased even more. Also, during last hospital stay,
patient underwent speech and swallow eval, and was found to be
aspirating thin fluids and nectar consistency. After discussion
with patient and his family, they agreed to allow him to
continue a diet with safety modifications understanding the
risks of aspiration. Recommendations are to pre-thicken all
liquids and foods prior to eating and to crush medications and
mix in apple cause or puree. Feeding tube was broached, but
family declined at the time. We contacted his cognitive
neurologist Dr. ___ and PCP ___, to discuss
their views on his longterm prognosis and they had recommended
to the family on multiple occasions that he be placed in a
nursing facility. Long term care goals were discussed with
ex-wife and son ___ ( the HCP ___ but they would
like to keep caring for him at home at this time.
During this admission, a family meeting was held with pt's wife,
son, attending (___) and RN. A concensus decision by
the family was made that pt should be DNR/DNI.
CHORNIC ISSUES
# Depression: Sertraline was continued
# Insulin dependent diabetes mellitus: ___ HbA1c 10.1.
Poorly controlled diabetes. Continued NPH and monitor on humulin
sliding scale.
# Thrombocytopenia: Chronic. Baseline in 120s, 128 on admission.
# Hypertension: Continued atenolol, HCTZ, lisinopril
# BPH: Continued tamsulosin.
TRANSITIONAL ISUSE
# CODE STATUS: DNR/DNI
# PENDING STUDIES: blood cultures (will follow up)
# MEDICATION CHANGES: none
# FOLLOWUP PLAN:
- PCP and neurology
- We recommended ___ Lift at home. Pt's son was instructed
to discuss with ALS outreach coordinator (___) for that.
- Family confirmed that pt will STOP day program and resume
home ___, ___ services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with PMHx HIV on HAART, who presents from ___
___ house with concern for TB. He was hospitalized at ___
from ___ through ___ while undergoing EtOH detox. The
plan was to transfer to ___ for continued detox, however
the patient developed C diff and went to ___ house
while completing his course of flagyl. He has since done so, but
noted the onset of a non-productive cough for the past 1 week,
worse at night as well as bilateral low back pain when he
coughs. Per records, he was seen by his PCP at ___,
Dr. ___ who was concerned and sent the patient in for
evaluation for TB. The patient reports 1 week fever on ___
but denies chills, night sweats, weight loss. He was
incarcerated for 76 days in ___ at some point during the
1980s. He reports never being homeless and no signifcant travel
history. Has no contacts that have been treated for TB before.
He states in the ___, he was hospitalized and sequestered out of
concern for TB which was negative. He also reports a PPD being
placed in ___ prior to his admission to ___ that was
negative. It was also noted a likely resolving zoster rash in
the T10 distribution.
.
In the ED, initial VS: 98.3 65 147/86 20 100% ra. Exam showed
RUL rhonchi as well as what appeared to be a healing zoster
infection. He had a CXR with RUL consolidation. Labs showed
leukocytosis to 2.7, H&H 10.5/28.4. He was given
ceftriaxone/azithromycin for pneumonia and admitted. On
transfer, vitals were: 99.7 60 18 148/80 96%RA.
.
Currently, the patient feels well, but is anxious about being
hospitalized. Per records sent with patient, he was restarted on
ARVs on ___ - unclear why they were stopped previously.
.
Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HIV on HAART - was followed at ___ but recently switched to
___
Hepatitis C
C diff
Anxiety
Depression
Seizure disorder of unclear etiology
COPD
ADHD
Social History:
___
Family History:
Denies CAD, sudden cardiac death. Brother with depression.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 147/100 65 18 100%RA
GENERAL - Alert, interactive, frail man in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP w/ brown pigment
along buccal mucosa
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB with coarse rhonchi RUL
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - Resolving rash along right upper chest and back - no
vesicles but hypopigmented areas remain - appears dermatomal
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact,
DISCHARGE PHYSICAL EXAM:
VS - 98.3 138/78 64 18 98%RA
GENERAL - Alert, interactive, NAD, edentulous
HEENT - PERRL, EOMI, sclerae anicteric, MMM
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - 1.5cm swath of mild ulceration on R upper back,
non-tender
NEURO - awake, A&Ox3, muscle strength ___ throughout
Pertinent Results:
ADMISSION LABS:
___ 09:15PM BLOOD WBC-2.7* RBC-3.15* Hgb-10.5* Hct-28.4*
MCV-90 MCH-33.2* MCHC-36.9* RDW-14.8 Plt ___
___ 09:15PM BLOOD Neuts-57.4 ___ Monos-8.3 Eos-3.6
Baso-1.2
___ 07:00AM BLOOD WBC-3.3* Lymph-24 Abs ___ CD3%-86
Abs CD3-677 CD4%-17 Abs CD4-135* CD8%-65 Abs CD8-514
CD4/CD8-0.3*
___ 01:21PM BLOOD UreaN-14 Creat-0.9 Na-133 K-4.1 Cl-101
HCO3-24 AnGap-12
___ 01:21PM BLOOD ALT-19 AST-36 AlkPhos-145* TotBili-0.2
___ 01:21PM BLOOD TotProt-7.8 Albumin-3.4* Globuln-4.4*
Calcium-8.8
___ 09:31PM BLOOD Lactate-1.0
PERTINENT INTERVAL LABS:
___ 07:40AM BLOOD WBC-3.4* RBC-3.41* Hgb-10.8* Hct-30.8*
MCV-90 MCH-31.6 MCHC-35.0 RDW-15.1 Plt ___
___ 07:40AM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-138
K-4.6 Cl-105 HCO3-26 AnGap-12
___ 07:40AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.7
MICRO:
___ 1:21 pm VIRAL CULTURE:R/O HERPES SIMPLEX VIRUS
**FINAL REPORT ___
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___:
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
___ 1:21 pm SWAB Site: BACK
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
BLOOD CULTURES X2 (___): NO GROWTH
___ 1:52 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
IMAGING
CXR (___):
TWO VIEWS OF THE CHEST:
The lungs are well expanded and show a right upper lobe opacity.
The
cardiomediastinal silhouette, hilar contours, and pleural
surfaces are normal. Mild opacification is noted also in the
left apex. Sutures are noted in the left apex.
IMPRESSION:
Right upper lobe and to a lesser extent left apical opacity
could be related to multifocal pneumonia. This appearance can be
seen in tuberculosis.
Medications on Admission:
1. MVI daily
2. Thiamine 100mg daily
3. Foilc acid 1mg daily
4. Acetaminophen 650mg q4prn
5. Maalox 200-200-20mg/5ml prn indigestion
6. Colace 100mg BID prn constipation
7. MOM 400mg/5ml prn constipation
8. Epipen prn anaphylaxis
9. Aspirin 325mg x1 prn chest pain
10. Zoloft 50mg daily
11. Trileptal 300mg BID
14. Albuterol HFA 2puffs q6hrs prn wheeze
15. Hydroxyzine 50mg PO bid prn anxiety
16. Azithromycin 1200mg weekly
17. metoprolol tartrate 12.5mg BID
18. Atovaquone 1500mg daily
19. Truvada 200-300 1 tab daily
20. Prezista 600mg BID
21. Norvir 100mg BID
22. Issentress 400mg BID
26. Clotrimazole 1% cream to feet BID
27. Mighty shake with each meal
28. Claritin 10mg ___
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for heartburn.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO
three times a day as needed for dyspepsia.
7. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular
PRN as needed for anaphylactic reaction.
8. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
11. hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for anxiety.
12. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(___).
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
14. atovaquone 750 mg/5 mL Suspension Sig: Two (2) doses PO
DAILY (Daily).
15. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. ritonavir 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Clotrimazole Foot 1 % Cream Sig: One (1) application Topical
twice a day.
20. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
21. valacyclovir 1 g Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days: Continue until ___.
Disp:*21 Tablet(s)* Refills:*0*
22. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
23. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: Continue until ___.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
patient ruled out for tuberculosis
URI
secondary diagnoses:
HIV
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with cough and fever, question tuberculosis.
COMPARISON: No relevant comparisons available.
TWO VIEWS OF THE CHEST:
The lungs are well expanded and show a right upper lobe opacity. The
cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal.
Mild opacification is noted also in the left apex. Sutures are noted in the
left apex.
IMPRESSION:
Right upper lobe and to a lesser extent left apical opacity could be related
to multifocal pneumonia. This appearance can be seen in tuberculosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: TB EVAL
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ASYMPTOMATIC HIV INFECTION
temperature: 98.3
heartrate: 65.0
resprate: 20.0
o2sat: 100.0
sbp: 147.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | ========================
BRIEF PATIENT SUMMARY
========================
___ y/o male with HIV on HAART who presents with cough x1 week.
Considering a CXR that demonstrated RUL opacity, the patient was
ruled out for TB.
========================
ACTIVE ISSUES
========================
# R/o TB - Cough for the past week, CD4+ count < 30, and
recently restarted on an anti-retroviral regimen. In setting of
CXR demonstrating left apical and right upper lobe opacity, hx
of living in group living and a distant hx of incarceration,
there is sufficient concern re: potential TB activation. Pt had
3 morning induced sputums to r/o TB: no acid fast bacilli on
smears or prelim cultures. Pt has had no fevers (although may
not mount substantial fever w/ current immune status),
hemodynamically stable, no sputum production and looks well:
will defer on treatment of PNA as clinical suspicion low at
present time. Cough likely secondary to URI.
.
# Zoster / HSV - Appears to have resolving zoster on right upper
back in ~T4 dermatome. Currently asymptomatic. As patient is
immunocompromised, we treated with valacyclovir 1gm TID. Pt to
complete a 10d course.
.
# HIV on HAART - pt recently restarted ARVs, while in house, we
continued ARVs. and continued azithromycin 1200mg weekly for ___
ppx, atovaquone daily for PCP ___
.
# Seizure disorder - Unclear etiology or history of seizures.
patient reports having seizure last year in setting of arrest of
unclear etiology. Continued trileptal
.
# Depression/anxiety - continued zoloft, hydroxyzine
=========================
TRANSITIONAL ISSUES
=========================
1. R/O TB: smears and prelim cultures neg for TB. PCP to ___
final cultures.
2. Medication changes:
STOP acetaminophen
CHANGE metoprolol from metoprolol tartrate 12.5mg twice per day
to metoprolol tartrate 25mg twice per day
START valacyclovir three times per day for seven days
(prescription attached)
START levofloxacin 750mg once per day for seven days
(prescription attached)
START benzonatate up to three times per day symptomatically for
cough
3. ___ appointment:
Name: ___.
Location: ___
Address: ___
Phone: ___
Appt: ___ at 4:10pm |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Refer from outside hospital with concern of Sub arachnoid
hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old right-handed woman with a hx head
trauma and subsequent sub dural hematoma who presents with
severe
headache, vomiting, and confusion. The history is obtained from
the patient and her daughter, who is at bedside. The patient
reports that she has been having throbbing headaches on and off
for the past month. They started after her brain aneurysm was
clipped, no prior headache history. Last night the headache
became worse, to the point that she also felt nauseated and
vomited once, she also felt spinning at this time. Her daughter,
who lives with her, also noticed that she was slightly more
confused than usual and that her voice sounded more slurred than
previously. She slept poorly that evening and her daughter
brought her to an OSH for evaluation at 0800. Since then the
headache remains but the other symptoms have resolved. They both
deny any head trauma or falls.
On neuro ROS, the pt reports last fell 9 months ago. She denies
loss of vision, blurred vision, diplopia, dysphagia. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
HTN
HL
psychosis/anxiety
Head trauma and sub dural hematoma s/p evacuation.
Hx of ischemic infarction in the left frontal area
Social History:
___
Family History:
Multiple people with aneurysms. Her cousin with a
brain aneurysm. Her father had what sounds like a AAA.
Physical Exam:
Physical Exam:
Vitals: T: 98.5 P: 100 BP: 135/86 RR: 16 SaO2: 100% RA
General: Awake, cooperative, slightly agitated about not
receiving home meds yet.
HEENT: NC/AT, no scleral icterus, dry MM, clear oropharynx
Neck: Supple, no nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Mildly inattentive, very
tangential in speech. Very focused on receiving home
medications,
particularly her antipsychotics. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes, despite cueing.
Graphesethesia intact. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Face with mild asymmetry of bone structure at rest,
symmetric facial musculature activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strengh.
-Motor: Normal bulk, tone throughout. No pronator drift. No
adventitious movements. No 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, pinprick, cold sensation
throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs
symmetric.
-Gait: Good initiation. Slightly wide-based, normal stride and
arm swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
CBC, CHEM 7 AND COAGS
WBC-4.5 RBC-3.03* Hgb-9.2* Hct-28.6* MCV-94 MCH-30.3 MCHC-32.2
RDW-13.6 Plt ___ PTT-26.2 ___
Glucose-163* UreaN-36* Creat-1.6* Na-141 K-4.3 Cl-108 HCO3-24
AnGap-13
ALT-14 AST-18
Albumin-4.0 Calcium-9.3 Phos-3.8 Mg-2.1
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Head CT, CTA on ___:
1. Right parietal lobe gyral hyperdensities could represent
subarachnoid
hemorrhage or laminar necrosis. MRI would be helpful in
differentiation. No
new edema or mass effect.
2. Patent neck and head vessels. No significant internal
carotid artery
stenosis by NASCET criteria.
3. 7 mm right lung apex subpleural nodule. If there is low
risk for lung malignancy, followup may be obtained at ___
months; otherwise, followup in ___ months is recommended.
MRI brain without contrast on ___:
IMPRESSION:
1. Right parietal subacute infarction with laminar necrosis and
hemosiderin staining but no acute subarachnoid hemorrhage.
2. Left frontal lobe encephalomalacia consistent with chronic
infarction.
___ 09:00AM BLOOD Neuts-65.5 ___ Monos-6.6 Eos-7.7*
Baso-1.4
___ 09:00AM BLOOD WBC-4.3 RBC-3.03* Hgb-9.1* Hct-28.6*
MCV-95 MCH-30.0 MCHC-31.7 RDW-13.5 Plt ___
___ 09:00AM BLOOD Glucose-132* UreaN-31* Creat-1.3* Na-142
K-4.6 Cl-111* HCO3-24 AnGap-12
___ 09:00AM BLOOD ALT-39 AST-50*
___ 08:50AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.8 Mg-2.1
Medications on Admission:
Medications:
simvastatin 20mg qAM
amlodipine 5mg qAM
trazodone 100mg TID
remeron 30mg qHS
seroquel 200mg qid
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
2. Mirtazapine 30 mg PO HS
RX *mirtazapine 30 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
3. Quetiapine Fumarate 200 mg PO QID
RX *quetiapine 200 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*5
4. traZODONE 100 mg PO TID
RX *trazodone 100 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*5
5. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
6. Aspirin EC 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Migraine headache
2. Brain laminar necrosis in the setting of previous trauma
3. Traumatic brain injury headache
4. Incidental nodule in the lung
5. Acute kidney injury secondary to IV contrast
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Reported subarachnoid hemorrhage from outside hospital.
COMPARISON EXAM: CT head, ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Coronal and sagittal reformats as
well as thin section bone algorithm reconstructions were also obtained.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect, or infarction. Subtle hyperdensity along the gray matter in the right
parietal lobe is stable since the prior study and appears most consistent with
laminar necrosis from an old small infarct. Additionally, hypodensity in the
left frontal lobe is also likely a sequela of prior infarct. Enlarged
ventricles and sulci is consistent with age-related atrophy. The basal
cisterns appear patent, and there is preservation of gray-white matter
differentiation.
No fractures are identified. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: Gyral hyperdensity in the right parietal lobe with appearance
consistent with laminar necrosis, a sequela of prior infarction. No evidence
of acute intracranial hemorrhage. MRI may be obtained for confirmation if
clinically indicated.
Radiology Report
HISTORY: ___ female with subarachnoid hemorrhage. Evaluate for
aneurysm.
COMPARISON: Multiple prior examinations, most recently head CT of ___.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast and multiplanar reformats were reviewed.
Subsequently, rapid axial imaging was performed from the level of the main
pulmonary artery through the brain during infusion of 3.5 cc of IV Omnipaque
contrast. Multiplanar MIP reformats were reviewed. Curved reformats and 3D
volume rendered images were processed on a separate workstation and reviewed
on PACS.
FINDINGS:
NON-ENHANCED HEAD CT:
Gyral hyperdensities in the right parietal lobe are overall similar to prior.
Encephalomalacia in the left frontal lobe consistent with a prior infarction
is unchanged. No new edema, mass effect, or acute territorial infarction.
Prominent ventricles and sulci are compatible with age-related volume loss.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
No fracture is identified. There is mucosal thickening of the right sphenoid
sinus with aerosolized secretion within. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are otherwise clear.
NECK CTA:
There is a normal 3 vessel arch. The bilateral vertebral arteries and common
carotid arteries are widely patent without evidence of dissection or
occlusion. There is no significant internal carotid artery stenosis by NASCET
criteria. The distal cervical internal carotid arteries measure 4.8 mm on the
right and 5.3 mm on the left.
There is slight anterior wedging of the C4 vertebral body. C5-6
disc-osteophyte complex effaces the ventral thecal sac. At this level,
uncovertebral hypertrophy causes severe bilateral neural foramen narrowing.
The thyroid gland is unremarkable. No lymphadenopathy by CT size criteria.
There is centrilobular emphysema in the lung apices. Right lung apex
peripheral subpleural nodule (3:14) measures 7 mm. There is retained
secretion within the upper trachea (3: 61).
HEAD CTA:
The intracranial internal carotid and vertebral arteries, and their major
branches, are patent without hemodynamically significant stenosis, dissection,
or aneurysm. The left vertebral artery is dominant.
IMPRESSION:
1. Right parietal lobe gyral hyperdensities could represent subarachnoid
hemorrhage or laminar necrosis. MRI would be helpful in differentiation. No
new edema or mass effect.
2. Patent neck and head vessels. No significant internal carotid artery
stenosis by NASCET criteria.
3. 7 mm right lung apex subpleural nodule. If there is low risk for lung
malignancy, followup may be obtained at ___ months; otherwise, followup in
___ months is recommended.
Findings were communicated via phone call by Dr. ___ to Dr. ___
___ on ___ at 13:50.
Radiology Report
HISTORY: ___ female with possible subarachnoid hemorrhage.
COMPARISON: Multiple prior exams, most recently CTA head of ___.
TECHNIQUE: MR sequences were obtained on a 1.5 T magnet through the brain
without administration of IV gadolinium contrast. Multiplanar T1 and T2
weighted images were obtained. DWI and ADC maps were obtained.
FINDINGS:
In the region of right parietal gyral hyperdensity seen on the prior CT, there
is a subacute infarction that has increased FLAIR signal with small regions of
slow diffusion. Curvilinear T1 hyperintensity that follows the contours of
the gyri is compatible with laminar necrosis. Small hemosiderin is also
present in this region, as demonstrated on gradient echo imaging, which may be
from a prior hemorrhage. No evidence of acute subarachnoid blood. Left
frontal lobe encephalomalacia is consistent with a chronic infarction. There
is no evidence of mass or mass effect.
The ventricles and sulci are prominent, compatible with age related volume
loss. The major intracranial vessel flow voids are preserved. Two left
frontal bone burr holes are present. Bone marrow signal intensity is
otherwise within normal limits. There is mucosal thickening of the right
sphenoid sinus. The imaged paranasal sinuses and mastoid air cells are
otherwise clear.
IMPRESSION:
1. Right parietal subacute infarction with laminar necrosis and hemosiderin
staining but no acute subarachnoid hemorrhage.
2. Left frontal lobe encephalomalacia consistent with chronic infarction.
Findings were discussed via phone call by Dr. ___ with Dr. ___
___ on ___ at 1124 AM.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 98.5
heartrate: 100.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 86.0
level of pain: 5
level of acuity: 2.0 | Pt is ___ yo RH woman with a hx of subdural hematoma s/p
evacuation who presented to an outside hospital with severe
headache, vomiting, and vertigo. She was transferred to ___
from OSH after CT head showed concern for possible subarachnoid
hemorrhage in the right parietal sulci. CTA was performed which
did not show any detectable intracranial aneurysm on ___.
CTA report mentionned that the hyperdensity in the right
parietal sulci was either cortical laminar necrosis or
subarachnoid hemorrhage. MRI brain showed that the right
parietal gyral lesion was actually cortical laminar necrosis.
There was no SAH seen. We also asked ___ to send her prior MRI
images but these were not available for our review during this
hospitalization.
Please note, that when the patient originally presented to
___, she said that she had a history of intracranial aneurysm.
However, review of written records at ___ showed that this was
not the case. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
severe L foot pain
Major Surgical or Invasive Procedure:
___ Bilateral lower extremity angiograms. Angioplasty of
the distal SFA using a Coyote over-the-wire 120 mm x 4 mm
balloon.
___ Right lower extremity angiogram. Balloon angioplasty
with 5 x ___ and 5 x 80 mm Impact Admiral drug-coated balloon of
the distal superficial femoral artery and proximal popliteal
artery
___ Left lower extremity angiogram. Angioplasty of the
left distal popliteal and tibioperoneal trunk with ___
over-the-wire 120 mm x 3 mm balloon.
___ Percutaneous angioplasty and placement of a 5 x ___
Tigris
stent in the left popliteal artery. Angioplasty and placement
of a 5 x ___ Innova stent in the left superficial femoral
artery.
___ Right fifth toe amputation, left foot wide excisional
debridement of bone and soft tissue including first and second
partial ray amputations.
History of Present Illness:
HPI: ___ with hx of htn, DM2, PAD s/p R ___ and ___ toe
amputation, L ___ toe and L hallux osteomyelitis on PO
levofloxacin/linezolid presenting with fever, chills, foot pain,
and dysuria. History is obtained from patient, with assistance
of
daughter ___.
Pt was hospitalized ___ and again ___ for L
hallux osteomyelitis and R fifth digit necrosis, during which
time there was recommendation for operative management. At that
point, pt was reluctant to proceed with surgery; plan was also
complicated by lapse of insurance, such that outpatient IV
antibiotics was no longer covered. Ultimately decision was made
to discharge patient home on levofloxacin/linezolin PO, to give
patient several days at home while deciding whether to proceed
with amputation. She was also scheduled to follow up with ID on
___. Pt declined to pursue surgery, and to follow up with ID
as scheduled. According to her daughter, pt has great dislike
for
hospitals, and typically recognizes progression of disease when
she sees physical changes in her feet.
Pt took abx for ___ weeks after discharge home, but subsequently
stopped all antibiotics because she believed that they were
causing stomach upset. She was off all antibiotics for about 3
weeks, and resumed the levofloxacin alone when pain began to
increase. Pt denies F/C, but daughter ___ reports that she
does
get hot and cold flashes. She describes ___ weeks of dysuria,
without hematuria, denies chest pain, SOB, cough, headache.
She describes L foot as pulsing, radiating proximally to L leg.
Pain has been progressive since returning home from the
hospital.
Patient had decided against surgical intervention in the
interim,
despite understanding the risks.
In the ___ ED:
VS 98.4, ___, 100% RA
Exam notable for exquisitely tender foot
Labs notable for WBC 15.6, Hb 10.0, plt 475
BUN 15
Cr 0.7
Na 134
INR 1.2
Lactate 1.6
Influenza negative
UA with pyuria, few bacteria
Imaging:
L ___ negative for DVT
Evaluated by podiatry:
"Patient with right foot with fifth toe bone exposed- no acute
signs of infection. Left foot with chronic hallux ulcer that
probes to bone with scant purulence, ___ necrotic toe- no
purulence, left heel blister with superficial wound. Left lower
extremity diffusely swollen and tender- negative ___.
Overall feet do not appear acutely infected however the patient
would benefit from surgical intervention after vascular work up.
Would recommend admission to medicine for continued infectious
work up, vascular studies, IV antibiotics."
Received:
Tylenol
Oxycodone 5 mg
Clindamycin
Zosyn
On arrival to the floor, pain is ___.
Past Medical History:
- HTN
- T2DM
- Right hallux and ___ toe amputations, ___ ___.
Social History:
___
Family History:
No family history of diabetes
Physical Exam:
Admission Physical Exam:
========================
VS: 98.2 PO 148 / 73 R Lying 96 18 97 Ra
GEN: alert and interactive, comfortable, no acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel
sounds, no hepatomegaly
EXTREMITIES: Bilateral trace pitting edema. R ___ toe with
exposed bone without surrounding erythema or drainage. S/p
amputation of R ___ and ___ toes. L hallux with ulceration
without active drainage. Dopplerable R DP. L ___ is dopplerable,
unable to Doppler L DP.
GU: no foley
SKIN: Bilateral ___ skin changes as above
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect
Pertinent Results:
Admission Labs:
===============
___ 10:17PM BLOOD WBC-15.6* RBC-3.74* Hgb-10.0* Hct-30.0*
MCV-80* MCH-26.7 MCHC-33.3 RDW-12.0 RDWSD-34.8* Plt ___
___ 10:17PM BLOOD Neuts-83.8* Lymphs-9.0* Monos-6.0
Eos-0.4* Baso-0.2 Im ___ AbsNeut-13.08* AbsLymp-1.40
AbsMono-0.94* AbsEos-0.06 AbsBaso-0.03
___ 10:17PM BLOOD ___ PTT-30.6 ___
___ 10:17PM BLOOD Glucose-206* UreaN-15 Creat-0.7 Na-134*
K-5.0 Cl-94* HCO3-22 AnGap-18
___ 06:50AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.1
___ 09:55AM BLOOD %HbA1c-11.4* eAG-280*
___ 06:50AM BLOOD CRP-218.7*
Imaging:
========
Xray Foot:
1. Findings concerning for osteomyelitis involving the middle
and distal
phalanges of the right fifth toe subjacent to an ulcer.
2. Osteolysis of the distal phalanx of the left great toe
remains concerning for osteomyelitis, similar to that seen on
the prior radiograph.
Lower Extremity Duplex US:
No evidence of deep venous thrombosis in the left lower
extremity veins.
US Noninvasives:
Severe bilateral obstructive arterial disease, most prominently
infrapopliteal.
Compared to ___, findings in the left lower extremity
demonstrate
reduction ABI. Right lower extremity findings are similar.
CTA Abd/Pelvis:
1. Severe multifocal bilateral lower extremity atherosclerotic
disease.
2. Occluded right distal superficial femoral and popliteal
arteries which
reconstitute at the distal popliteal artery.
3. Occluded left popliteal artery which reconstitutes at the
trifurcation.
4. Severe focal stenosis of the mid to distal left superficial
femoral artery.
5. Severe stenosis of the bilateral anterior tibial arteries
with attenuated by likely patent dorsalis pedis bilaterally.
6. Diminutive abdominal aorta, likely congenital.
7. Prominent left common iliac and inguinal lymph nodes, likely
reactive.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Levofloxacin 500 mg PO Q24H
3. Lisinopril 20 mg PO DAILY
4. MetroNIDAZOLE 500 mg PO Q8H
5. Linezolid ___ mg PO Q12H
6. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain
DO NOT TAKE MORE THAN 4000MG IN A 24 HOUR PERIOD
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
3. Aspirin 81 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*3
5. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Please take one dose daily (every 24 hours) until ___
RX *ertapenem 1 gram 1 g IV DAILY Disp #*36 Vial Refills:*0
6. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*3
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6HR:PRN Disp #*10
Tablet Refills:*0
8. Atorvastatin 40 mg PO QPM
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11.Outpatient Lab Work
ICD-10-CM Diagnosis Code ___ / OSTEOMYELITIS
WEEKLY CBC with differential,
BUN, Cr, AST, ALT,
Total Bili, ALK
PHOS, CRP
OPAT Diagnosis: osteomyelitis
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: ertapenem 1g q24h
Start Date: ___
Projected End Date: ___
ALL LAB RESULTS SHOULD BE SENT TO :
ATTN: ___ CLINIC - FAX: ___
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ischemic rest pain
osteomyelitis
Post operative anemia requiring transfusion
Hypertension
urinary retention / mobility issue and behavioral
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with left foot osteomyelitis. Tenderness to
palpation in calf up to knee// DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None available
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow left demonstrated in
the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old woman with diabetic foot ulcer, PAD// please eval for
PAD, *needs lower extremity runoff* Plan for likely angiogram and possible
revascularization
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 20.0 s, 129.9 cm; CTDIvol = 3.6 mGy (Body) DLP =
460.4 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 5.8 mGy (Body) DLP = 1.2
mGy-cm.
3) Stationary Acquisition 9.6 s, 0.2 cm; CTDIvol = 162.9 mGy (Body) DLP =
32.6 mGy-cm.
4) Spiral Acquisition 20.1 s, 130.3 cm; CTDIvol = 9.6 mGy (Body) DLP =
1,246.9 mGy-cm.
5) Spiral Acquisition 10.0 s, 64.9 cm; CTDIvol = 8.8 mGy (Body) DLP = 562.5
mGy-cm.
Total DLP (Body) = 2,304 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. In fact, the abdominal aorta is
diminutive measuring approximately 1.0 cm in the infrarenal portion, likely
congenital. There is mild calcium burden in the abdominal aorta and great
abdominal arteries. There is extensive irregularity in lower extremity
arteries suggestive of multifocal atherosclerotic disease as follows.
CTA abdomen/pelvis:
1. Abdominal aorta:Congenital stenosis.
2. Celiac axis: No stenosis.
3. SMA: No stenosis.
4. ___: Mild to moderate stenosis at the origin.
5. Renal arteries: Left: Minimal stenosis.; Right: No stenosis.
6. Left common iliac: No stenosis.
7. Right common iliac: No stenosis.
8. Left external iliac: No stenosis.
9. Right external iliac: No stenosis.
10. Left internal iliac: No stenosis.
11. Right internal iliac: No stenosis.
CTA run-off RLE:
1. Common femoral artery: No stenosis.
2. Superficial femoral artery: Moderate stenosis in the midportion (5:185),
occluded distally (5:209).
3. Deep femoral artery: No stenosis.
4. Popliteal artery: Mostly occluded, reconstitutes distally.
5. Anterior tibial artery: Severe stenosis (70-99%).
6. Posterior tibial artery: Mild stenosis (<50%).
7. Peroneal artery: Mild stenosis (<50%).
8. Dorsalis pedis: Severe stenosis (70-99%), attenuated, although likely
patent.
CTA run-off LLE:
1. Common femoral artery: No stenosis.
2. Superficial femoral artery: Mild stenosis (<50%) proximally, severe
stenosis distally (5:208).
3. Deep femoral artery: No stenosis.
4. Popliteal artery: Occluded (5:256) and reconstitutes at the trifurcation.
5. Anterior tibial artery: Severe stenosis (70-99%).
6. Posterior tibial artery: Mild stenosis (<50%).
7. Peroneal artery: Mild stenosis (<50%).
8. Dorsalis pedis: Attenuated although likely patent.
LOWER CHEST: Atelectasis is noted in the lung bases. There is no pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
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. A 2.0 cm cyst spleen is present in the splenic
hilum.
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. Colon and rectum are within normal limits. There
is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
Mildly prominent left common iliac lymph node measures 0.8 cm in short axis
(5:78).
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 uterus and bilateral adnexae are within normal
limits.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are present in the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Left
inguinal lymph nodes are prominent measuring 1.0 cm in short axis (05:147).
IMPRESSION:
1. Severe multifocal bilateral lower extremity atherosclerotic disease.
2. Occluded right distal superficial femoral and popliteal arteries which
reconstitute at the distal popliteal artery.
3. Occluded left popliteal artery which reconstitutes at the trifurcation.
4. Severe focal stenosis of the mid to distal left superficial femoral artery.
5. Severe stenosis of the bilateral anterior tibial arteries with attenuated
by likely patent dorsalis pedis bilaterally.
6. Diminutive abdominal aorta, likely congenital.
7. Prominent left common iliac and inguinal lymph nodes, likely reactive.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old woman with DM2, bilateral diabetic foot ulcers with
osteomyelitis, evaluating for operative management. Please obtain ABI/PVR.
Thank you.// ___ year old woman with DM2, bilateral diabetic foot ulcers with
osteomyelitis, evaluating for operative management. Please obtain ABI/PVR.
Thank you.
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements at rest.
COMPARISON: ___
FINDINGS:
On the right-side, triphasic Doppler waveforms were seen at the right femoral
and monophasic at the popliteal, posterior tibial, and dorsalis pedis
arteries. The right ABI was 0.40 at rest. Pulse volume recordings
demonstrate normal at the low thigh, moderately abnormal at the calf, severely
abnormal at the ankle and metatarsal.
On the left-side, triphasic Doppler waveforms were seen at the left femoral
and monophasic at the popliteal, posterior tibial, and dorsalis pedis
arteries. The left ABI was 0.29 at rest. Pulse volume recordings demonstrate
mildly abnormal at the low thigh, moderately abnormal at the calf, severely
abnormal at the ankle and metatarsal.
IMPRESSION:
Severe bilateral obstructive arterial disease, most prominently
infrapopliteal.
Compared to ___, findings in the left lower extremity demonstrate
reduction ABI. Right lower extremity findings are similar.
Radiology Report
EXAMINATION: VENOUS MAPPING of lower extremity superficial veins
INDICATION: ___ year old woman with bilateral PAD and ulcers. Vein mapping for
potential bypass// evaluate vein for potential bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both greater
saphenous veins.
COMPARISON: None
FINDINGS:
RIGHT:
The right greater saphenous vein in the proximal thigh measures 0.45 cm,
midthigh 0.21 cm, distal thigh 0.28 cm, mid knee 0.29 cm, proximal calf 0.25
cm, mid calf 0.14 cm, distal calf 0.19 cm.
The right small saphenous vein in the proximal calf measures 0.17 cm, mid calf
0.12 cm, distal calf 0.12 cm.
LEFT:
The Left greater saphenous vein in the proximal thigh measures 0.52 cm,
midthigh 0.45 cm, distal thigh 0.23 cm, mid knee 0.27 cm, proximal calf 0.31
cm, mid calf 0.13 cm, distal calf 0.19 cm.
The left small saphenous vein in the proximal calf measures 0. 1 6 cm, mid
calf 0.12 cm, distal calf 0.15 cm.
IMPRESSION:
Patent greater and small saphenous veins bilaterally with measurements as
above.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ HT, DM2, PAD s/p R ___ and ___ toe amputation presenting with
L ___ and ___ toe osteomyelitis and R ___ toe osteomyelitis s/p L SFA PTA, now
RLE with PTA, has L sided area of ulceration, ID wants to know if any
underlying osteo// underlying osteomyelitis?
TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula
COMPARISON: None
FINDINGS:
No fracture is detected in the tibia or fibula. No suspicious lytic lesion,
sclerotic lesion, or periosteal new bone formation is detected. No soft tissue
calcification or radio-opaque foreign bodies are detected. Limited assessment
of the knee and ankle joint is unremarkable. The questionable skin defect
over the mid medial left lower leg.
IMPRESSION:
No radiographic evidence of osteomyelitis involving the left tibia or fibula.
Radiology Report
INDICATION: ___ year old woman s/p angioplasty of native occluded popliteal to
TP trunk, now open// Please evaluate baseline velocities now that occlusion
open in left leg
TECHNIQUE: Grayscale ultrasound, color Doppler, and spectral Doppler
waveforms of the right lower extremity were obtained.
COMPARISON: CTA dated ___
FINDINGS:
Peak systolic velocities are as follows:
Common femoral artery waveform is monophasic. Peak systolic velocity is 76
cm/sec.
Proximal superficial femoral artery waveform is dampened monophasic. Peak
systolic velocity is 66 cm/sec
Mid superficial femoral artery waveform is dampened monophasic. Peak systolic
velocity is 33 cm/sec
Distal superficial femoral artery waveform is dampened monophasic. Peak
systolic velocity is 42 cm/sec
Popliteal artery waveform is dampened monophasic. Peak systolic velocity is
22 cm/sec
Posterior tibial artery waveform is dampened monophasic. Peak systolic
velocity is 41 cm/sec
Peroneal artery waveform is dampened monophasic. Peak systolic velocity is
10 cm/sec
Anterior tibial artery waveform is dampened monophasic. Peak systolic
velocity is 10 cm/sec
Arteries are patent throughout the left lower extremity, but monophasic
waveforms throughout suggest more proximal arterial insufficiency. However,
dampened monophasic waveform beginning at the proximal superficial femoral
artery suggests a focal stenosis in the distal common femoral or proximal
superficial femoral artery.
IMPRESSION:
Patent arteries throughout the left lower extremity but waveform suggesting
proximal stenosis.
Additional findings suggestive of focal stenosis in the distal common femoral
or proximal superficial femoral artery.
Radiology Report
INDICATION: ___ HT, DM2, PAD s/p R ___ and ___ toe amputation presenting with
L ___ and ___ toe osteomyelitis and R ___ toe osteomyelitis s/p L SFA PTA, RLE
with PTA, LLE pedal access PTA// Please get ABIs and toe pressures
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: Arterial duplex dated ___
FINDINGS:
On the right side, biphasic Doppler waveforms in the femoral and popliteal
arteries but monophasic waveforms in the posterior tibial and dorsalis pedis
arteries.
The right ABI was 0.74.
On the left side, monophasic Doppler waveforms are seen in the femoral and
popliteal arteries, but are absent in the posterior tibial and dorsalis pedis
arteries.
The left ABI was 0.
Pulse volume recordings showed symmetric amplitudes bilaterally, at all
levels.
IMPRESSION:
Moderate right lower extremity arterial insufficiency at the level of the
tibial arteries, and severe left lower extremity arterial insufficiency,
likely multilevel including at the levels of the iliac artery and tibial
arteries.
Radiology Report
Study arterial duplex unilateral
Reason gangrene
Findings duplex evaluations performed left lower extremity is included the SFA
and popliteal stents. Starting the proximal common femoral artery extending
through the stents velocities are 105, 96, 420, 192, 94, 71, 136, 109, 103
No flow is identified in the proximal anterior and peroneal artery.
Posterior tibial artery is patent shows losses of 125, 120, 157
In the distal common femoral artery there is a step up of 4 X consistent with
a 50-99% stenosis.
Impression patent SFA and popliteal stents patent posterior tibial artery.
Stenosis in the left common femoral artery.
Radiology Report
Study arterial extremity rest
Reason gangrene
Findings Doppler evaluation was performed of both lower extremities. All
waveforms are monophasic throughout. The right ankle-brachial index is 0.62.
Pulse from recordings show mild drop-off the calf and ankle.
On the left pulse volume recordings show significant improvement from prior
study with maintenance and including the metatarsal. No toe pressure could be
identified because of gangrene. ABI has increased to 0.72
Impression bilateral multi segmental occlusive disease of note there has been
significant improvement in the left leg compared to prior study
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL BILATERAL
INDICATION: ___ year old woman s/p right ___ toe amp, left ___ ray amps//
s/p right ___ toe amp, left ___ ray amps
TECHNIQUE: AP, lateral and oblique view radiographs of the feet.
COMPARISON: Bilateral foot radiographs ___.
IMPRESSION:
RIGHT FOOT:
There are postsurgical changes from ___ and ___ toe amputations at the level
of the metatarsophalangeal joints, and partial amputation of the middle and
distal phalanges of the ___ toe, and distal phalanx of the ___ toe. There is
no acute fracture or dislocation. Mild degenerative changes of the midfoot and
remaining interphalangeal joints have not significantly progressed. There are
dorsal and plantar calcaneal spurs. Diffuse soft tissue swelling is seen
around the forefoot.
LEFT FOOT:
There are postsurgical changes from amputation of the ___ and ___ digital rays
at the level of the metatarsal heads. No acute fracture or dislocation is
identified. Mild degenerative changes of the midfoot are similar to prior
study. There are dorsal and plantar calcaneal spurs. Diffuse soft tissue
swelling is seen around the forefoot. There is an apparent soft tissue
deformity/ulceration along the heel.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 37cm length
___ ___ Contact name: ___: ___
TECHNIQUE: Chest AP
COMPARISON: Comparison to prior radiograph studies dated ___ and ___.
FINDINGS:
Right sided PICC line terminates in the right atrium. Lung volumes are
decreased. Cardiomediastinal silhouette is unchanged. No focal
consolidation. No pneumothorax or pleural effusion. Interval development of
mild pulmonary vascular congestion.
IMPRESSION:
Right-sided PICC line terminating in the right atrium. Line should be
retracted approximately 3.5 cm.
NOTIFICATION: The findings were discussed with ___, R.N. by ___
___, M.D. on the telephone on ___ at 3:57 pm, 15
minutes after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Foot pain
Diagnosed with Type 2 diabetes mellitus with foot ulcer, Type 2 diabetes w diabetic peripheral angiopathy w gangrene, Non-prs chronic ulcer oth prt left foot with oth severity, Essential (primary) hypertension, Pure hypercholesterolemia, unspecified
temperature: 98.4
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 207.0
dbp: 161.0
level of pain: 10
level of acuity: 3.0 | ___ ___ with hx of htn, DM2, PAD s/p R ___ and ___ toe
amputation, L ___ toe and L hallux osteomyelitis on PO
levofloxacin/linezolid presenting with progressive of
osteomyelitis/soft tissue infection in setting of
discontinuation of antibiotics.
# Bilateral diabetic foot ulcers c/b osteomyelitis: Has had
extensive prior evaluation, with prior wound cultures growing
group B strep, staph aureus, and coag negative staph. Pt had
been d/ced on ___ with clearly defined plan for close follow
up, both from surgical and infectious perspective. Unfortunately
pt's
aversion to medical system led to discontinuation of
antibiotics, without ID or podiatric follow up. She was started
on vanc/cefepime/flagyl, later changed to vancomycin and unasyn
per ID recommendations. She had non-invasive and CTA showing
severe PAD. Vascular surgery performed an angiogram.
# DM2: HbA1c elevated at 11.4. Treated with lantus and ISS
# PAD: resumed home statin and aspirin
# HTN: resumed home lisinopril (patient not taking at home)
On POD1 (___) from ultrasound guided access to the right
common femoral artery and placement of a ___ sheath,
selective catheterization of the left popliteal artery, third
order vessel, bilateral lower extremity angiograms, and
angioplasty of the distal SFA, the patient had SBPs in the 180s
and was given hydralazine x1, which reduced systolic BPs to
150-160s. On POD2 (___), the patient underwent vein mapping
and per ID vancomycin was held and the patient was continued on
ampicillin/sulbactam. On POD3 (___) the patient was kept
NPO after MN for RLE angiogram scheduled for ___. On POD 4
(___), the patient underwent an uncomplicated RLE angiogram
w/ angioplasty of SFA/popliteal with drug eluting balloon. On
___ patient was doing well post angiogram w/ angioplasty
with stable WBC and wounds, with no acute events. On ___
vascular medicine was consulted for uncontrolled hypertension
and the patient was started on 10mg of amlodipine and labetalol
300mg PO TID. ___ also worked with her on ambulation and
improving functional mobility. On ___ patient underwent
selective catheterization of the left SFA as well as left
posterior tibial artery and left lower extremity angiogram
angioplasty of the left distal popliteal and tibioperoneal trunk
and was given 1 unit PRBCs for anemia. On ___, patient had
no acute events and was seen by podiatry with recommendations
for continued vascular workup for optimal healing. On ___,
patient's lisinopril was increased from 20 to 40mg per Vascular
medicine for continued blood pressure control as well as worked
with ___ on ambulation and functional mobility. On ___,
patient had no acute events. Was seen by ___ as well as nutrition
which encouraged PO as tolerated and Glucerna TID. On ___
patient's PTT in the ___, increased rate to 1450 from 1350, with
plan to recheck PTT. Patient was given nebulizer and cough
suppressants for symptom improvement and made NPO after MN. On
___, patient had low Mg and was repleted. PTT recheck was
74.3. On ___, patient underwent selective catheterization
of the superficial femoral artery on the left w/ angiogram and
percutaneous angioplasty with stent placement in the popliteal
artery and left superficial femoral artery. On ___, a knee
immobilizer placed post-op and f/u with nutrition. On ___,
patient underwent right foot ___ digit amputation, left foot ___
and ___ partial ray amputations with podiatry. On ___,
patient was recovering well; received 5mg po oxy o/n, tolerating
regular diet and voiding. On ___, patient was restarted on
hep gtt 500 u/hr and was seen by ID with recs to remain on
ampicillin/sulbactam while in-patient, then give first dose
ertapenem prior to discharge with 6 week duration. On ___,
patient had no acute events. Hep ggt was titrated to 950/hr. On
___, patient's vac was taking down and had drop in
hematocrit to 21.4 and refused blood at that time. On ___,
patient continued to refuse blood. The heparin drips was stopped
and was continued on ASA/Plavix. We started iron and consented
for PICC, which was placed same day. On ___ patient has a
rehab bed and will be ready for dispo pending podiatry recs on
wound care.The patient's family did not want rehab, so they were
discharged home on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
aspirin / clindamycin / Keflex
Attending: ___
Chief Complaint:
Right basal ganglia hemorrhage
Major Surgical or Invasive Procedure:
-EVD placement (___)
-Endotracheal intubation
-Tracheostomy (___)
-Open G tube placement (___)
History of Present Illness:
This is a ___ M with a history of hypertension, prior right
CEA, prior gastric bleeding while on aspirin therapy, HLD and
tobacco and alcohol abuse who is transferred from ___
for the management of a hemorrhagic
stroke. The patient provides a good history, and his wife is
with him at this time.
He reports that his health has been well lately. This morning,
he woke up at 4am and was feeling fine. He denies headache or
problems with his vision at the time. He was in his work shop
sawing a piece of wood at around 1030am (as best as he can
guess) when he suddenly felt a sense of discomfort and
dysequilibrium, "like an inner ear problem". He was quite
unsteady on his feet
and so he fell to the ground, but did not hit his head. He did
scratch his left eyebrown on the way down. He was able to crawl
for a few steps and was able to get his wife. His wife noted
that he had not taken his medication (notably his BP
medications) and so she gave him his "enapril" in his mouth. EMS
was called, where he was taken to ___ and noted to have
the right sided hypertensive hemorrhage as noted below. He was
started on a labetalol drip and transferred to ___. His wife
reports that it is unusual that he would forget to take his
medications. He has not since fallen, but he hasn't really been
on his feet.
At this time, he reports a "mild headache", but denies any
problems with neck stiffness, difficulty speaking or
understanding.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Neurological Review of Systems: Positive for some shaking tremor
noted by wife. Negative for asymmetric weakness, numbness,
diplopia, dysarthria, dysphagia, tongue numbness, change in
taste, loss of consciousness, jerking/twitching episodes. No
pins/needles sensations, numbness. Negative for problems with
blurry vision or loss of vision.
Past Medical History:
- right CEA: patient reports having his "right neck artery
cleaned out" ___ years ago. He does not recall any specific
symptoms, but his wife says, "isn't that when you were having
some spots in your right eye?"
- Hypertension: no prior strokes or MIs per patient
- Hypercholesterolemia
- Bleeding gastric ulcers, further details are unknown at this
time
- COPD: longstanding history of tobacco abuse, currently on
spiriva therapy. No prior admissions for COPD exacerbation
- Lumbar spinal stenosis, noticed after a fall and back injury
Social History:
___
Family History:
Positive for hypertension in several family members, no
neurologic illnesses, history of breast cancer in one aunt.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: HR 98, BP 183/100, RR 19, 98% O2
General: Awake, cooperative, looks tired and exhausted,
otherwise quite pleasant. Towards the end of the examination,
reported some breathing discomfort and asked for his inhaler.
HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions
noted in oropharynx, small well healed laceration by his right
eyebrow
Neck: Supple, no masses or lymphadenopathy
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to ___. Able to
relate history without difficulty. Inattentive, struggles with
___ backwards, but can ___ forwards. Language is fluent with
intact repetition and comprehension. Cannot calculate 9+13, and
has some delayed reaction times occasionally. Normal prosody.
There were no paraphasic errors. Repeats well, and follows
commands. Pt. was able to name high frequency objects. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. The pt. had good
knowledge of current events. Extinguishes to DSS on the left
without left right confusion or significant left sided sensory
loss. Follows crossed body commands well.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV and VI: EOM are intact and full, no nystagmus, but with
some saccadic intrusions at first
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue is strong
-Motor: Normal bulk, tone is slightly increased bilaterally in
lower extremities. Prominent left sided pronator drift. Action
tremor noted on the right > left. No pronator drift bilaterally.
No asterixis noted. I observed 4+ weakness of the right TA and
IP, and hamstrings on the right.
-Sensory: No deficits to light touch, pinprick is not reduced
anywhere or in a stocking distribution. He is insensate to
vibration in his toes, with normal JPS. Vibration is normal at
the ankles.
DTRs:
Bi Tri ___ Pat Ach
L ___ 3Ca 1
R ___ 3Ca 1
Ca: crossed adductors
Plantar response: Extensor on the left
-Coordination: Action tremor noted on the right when asked to
FTN. On the left, he is slow but accurate.
-Gait: Deferred
========================
DISCHARGE PHYSICAL EXAM:
========================
- Vitals: 99.1/98.4, 129/63 [117-155/88-92], HR 77-94, RR 37
[___], SaO2 98% CPAP ___
- General exam: notable for softly distended abdomen (positive
bowel sounds), mild anasarca throughout.
- Neuro exam:
--MENTAL STATUS: eyes open spontaneously. Tracks examiner around
room to left and right. Intermittently responds appropriately to
questions with yes/no head nod. Follows commands on right (show
2 fingers, wiggles toes).
--CRANIAL NERVES: PERRL 3->2 bilaterally. Extraocular movement
testing limited by cooperation, but able to track to left and
right. Left lower facial droop.
--MOTOR: RUE moves purposefully with proximal weakness,
antigravity strength distally. RLE moves purposefully and at
least ___ in proximal extremity, able to flex knee and wiggle
toes. Moves distal LUE in plane of the bed. LLE triple flexion.
Increased tone in left arm and leg.
--SENSORY: intact to noxious stim throughout
--REFLEXES: toes upgoing bilaterally.
Pertinent Results:
ADMISSION LABS:
-WBC-11.5* RBC-4.65 Hgb-14.5 Hct-44.7 MCV-96 MCH-31.1 MCHC-32.4
RDW-11.9 Plt ___
-Neuts-80.7* Lymphs-13.1* Monos-4.3 Eos-1.4 Baso-0.5
-___ PTT-30.5 ___
-Glucose-134* UreaN-12 Creat-0.6 Na-133 K-4.2 Cl-100 HCO3-23
AnGap-14
-URINE Color-Straw Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-7.5 Leuks-NEG
CSF STUDIES:
___ 02:18AM CEREBROSPINAL FLUID (CSF) WBC-49 RBC-6290*
Polys-31 ___ Monos-2 Eos-2
___ 02:18AM CEREBROSPINAL FLUID (CSF) TotProt-54*
Glucose-87
___ 09:01AM CEREBROSPINAL FLUID (CSF) WBC-11 ___
Polys-60 ___ Monos-9 Eos-5
___ 09:01AM CEREBROSPINAL FLUID (CSF) TotProt-58*
Glucose-88
___ 09:30PM CEREBROSPINAL FLUID (CSF) WBC-100 RBC-4850*
Polys-60 ___ Monos-12 Eos-4
___ 09:30PM CEREBROSPINAL FLUID (CSF) TotProt-49*
Glucose-96
___ 12:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-11* Polys-0
___ ___ 12:50PM CEREBROSPINAL FLUID (CSF) TotProt-35 Glucose-76
___ 12:40PM CEREBROSPINAL FLUID (CSF) WBC-1625 RBC-50*
Polys-73 ___ Monos-0 ___ Macroph-18
___ 12:40PM CEREBROSPINAL FLUID (CSF) TotProt-503*
Glucose-17
___ 12:40PM CEREBROSPINAL FLUID (CSF) WBC-2900 RBC-100*
Polys-72 ___ Monos-0 ___ Macroph-19 Other-1
___ 02:09PM CEREBROSPINAL FLUID (CSF) TotProt-119*
Glucose-61
___ 02:09PM CEREBROSPINAL FLUID (CSF) WBC-31 RBC-6*
Polys-23 ___ Macroph-6
___ 02:09PM CEREBROSPINAL FLUID (CSF) WBC-47 RBC-0 Polys-31
___ Monos-0 ___ Macroph-12
MICROBIOLOGY:
- BCx (___): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES:
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
- CSF Cx (___):
VIRIDANS STREPTOCOCCI. 2 COLONIES .
Sensitivity testing performed by Sensititre.
CLINDAMYCIN MIC= 0.12 MCG/ML.
REPORTED LINEZOLID PER ___. ___ ___.
VIRIDANS STREPTOCOCCI. 1 COLONY ON 1 PLATE. SECOND
MORPHOLOGY.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN MIC = 0.12 MCG/ML.
REPORTED LINEZOLID PER ___. ___ ___ .
ENTEROCOCCUS FAECIUM.
1 COLONY ON 1 PLATE ISOLATED FROM REPLANTED SPECIMEN .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
| VIRIDANS STREPTOCOCCI
| | ENTEROCOCCUS
FAECIUM
| | |
AMPICILLIN------------ =>32 R
CLINDAMYCIN----------- S S
ERYTHROMYCIN----------<=0.25 S 1 R
LINEZOLID------------- 1 S <=0.5 S 2 S
PENICILLIN G----------<=0.06 S 0.25 I
VANCOMYCIN------------ <=1 S 1 S =>32 R
CSF Cx (___):
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___ 14:31.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1
PLATE.
SPECIMEN BEING REPLANTED ___. REPLANTED SPECIMEN = NO
GROWTH.
NCHCT (___): There is extensive intraventricular hemorrhage
involving predominantly right lateral ventricle, extending into
the frontal horn of the left lateral ventricle as well as the
third ventricle. No hemorrhage is seen within the fourth
ventricle. Intraventricular hemorrhage essentially unchanged in
distribution since the study obtained nine hours prior. There
is an intraparenchymal hemorrhage centered in the right basal
ganglia and extending into the thalamus, which now measures 2.5
x 1.5 cm, unchanged since prior. There is surrounding vasogenic
edema. No new focus of intracranial hemorrhage is detected.
There is no hydrocephalus. Basal cisterns are patent. The
sulci and ventricles are unchanged in size and configuration
since prior and are slightly prominent, likely age-related
involutional changes. Confluent
hypodensities in periventricular, subcortical and deep white
matter
distribution likely reflect sequela of small vessel ischemic
disease. There is moderate thickening of the ethmoid air cells.
Otherwise, imaged paranasal sinuses and mastoid air cells are
well aerated. No acute fracture is detected. The orbits are
unremarkable.
IMPRESSION: In comparison to study obtained nine hours prior,
there is no significant change in the intraventricular and
intraparenchymal hemorrhage, as described above. No new
intracranial hemorrhage.
NCHCT (___): Slight interval decrease in the right basal
ganglial hemorrhage, extending into the thalamus. Degree of
associated intraventricular hemorrhage within the right lateral
ventricle and third ventricle is also decreased. No new
intracranial hemorrhage.
EEG (___): This is an abnormal continuous 16 hour ICU EEG
recording. There are three pushbuttons for one clinical event.
On video, patient withdraws from pain and moaning with no EEG
seizure correlate. The background activity shows generalized
slowing and alternating from moderate to severe encephalopathy
to severe encephalopathy of unknown etiology. There are no
epileptiform discharges or seizures recorded.
NCHCT (___): Small focus of blood products adjacent to a
right frontal burr hole. Otherwise no significant interval
change from NECT of the head obtained less than two hours prior.
EEG (___): This is an abnormal continuous 6.5 hour ICU EEG
recording. There is no pushing button event. The background
activity shows generalized slowing and alternating from
moderate-to-severe encephalopathy to severe encephalopathy,
likely due to sedation effect on top of
metabolic/toxic/infectious etiology. There are no epileptiform
discharges or seizures recorded.
EKG (___): Artifact is present. Atrial fibrillation with a
rapid ventricular response. Non-specific ST-T wave changes. No
previous tracing available for comparison.
EKG (___): Sinus tachycardia with premature atrial
complexes. Borderline left atrial abnormality. Delayed R wave
transition. Non-specific ST segment flattening in the
inferolateral leads. Compared to the previous tracing of ___
atrial fibrillation with a rapid ventricular response rate is no
longer appreciated and the atrial ectopy is new.
EKG (___): Sinus rhythm. Vertical axis. Diffuse non-specific
ST-T wave abnormalities, unchanged from the previous tracing.
CXR (___): Large scale asbestos-related pleural
calcification obscures much of the lungs, particularly
inferiorly. Comparing today's study to ___, previous
mild pulmonary edema has definitely improved, and atelectasis
has worsened. Small pleural effusions may now be present.
Moderate cardiomegaly is unchanged. ET tube is in standard
placement and an upper enteric drainage tube ends in the mid
portion of a non-distended stomach. No pneumothorax.
NCHCT (___):
1. Right frontal approach ventriculostomy catheter terminating
in the frontal horn of the right lateral ventricle. Minimal
decrease in the amount of hydrocephalus compared to the CT from
4 days prior upper
2. Evolving right thalamic hemorrhage without any evidence of
new hemorrhage.
NCHCT (___):
1. Evolving right thalamic hematoma without evidence of new
hemorrhage.
2. Ventricular size stable from prior exam.
KUB (___): No free air. Multiple up to 3.5 cm dilated small
bowel loops. Air in the colon and rectum. These findings likely
represent early small bowel obstruction, less likely ileus.
CXR (___): Heavy asbestos-related pleural calcifications
obscure much of the lower lungs, but nevertheless I can see that
there is mild edema in the lower lungs and small pleural
effusions that were not present on ___ and have worsened
since ___. More confluent opacity at the base of the
right lung could be either atelectasis or early pneumonia and
should be followed carefully. ET tube tip is at the upper margin
of the clavicles, no less than 10 cm from the carina and should
be advanced 4 cm for more secure seating. A feeding tube ends
in the upper stomach.
NCHCT (___):
1. Right thalamic hematoma, unchanged from prior exam.
2. Stable ventricular size from prior exam.
3. No new acute intracranial findings.
NCHCT (___):
1. Interval change in position of the EVD, which is now
positioned with the tip just inside the skull. Once the EVD is
completely removed, a followup CT is recommended to insure that
no catheter fragments remain intracranially.
2. Stable right thalamic hematoma with appropriately evolving
blood products.
3. Stable ventricular size from prior exam.
4. No new acute intracranial findings.
LENIs (___): No evidence of bilateral lower extremity DVT.
KUB (___): A Dobbhoff tube and nasogastric tube terminate in
the gastric body. Multiple dilated small bowel loops are seen
measuring up to 53 mm, slightly progressed since the prior study
38 mm. Air is seen within a mildly distended colon to the level
of the rectum. Supine
radiograph is limited for assessment of free air, within this
limitation, no free air is identified.
IMPRESSION: Diffusely dilated small and large bowel loops,
likely represent ileus.
CXR (___): As compared to the previous radiograph, there is
unchanged evidence of relatively extensive calcified pleural
plaques. Therefore, assessment of the lung parenchyma is
severely limited. The patient presents unchanged evidence of
mild cardiomegaly. The monitoring and support devices are
unchanged, except for the right PICC line that has been removed
in the interval. No pneumothorax.
CXR (___): Heavy pleural calcification due to asbestos
exposure obscures large areas in the lower lungs, but symmetric
increase in radiodensity in the lung bases is probably due to
pulmonary edema. But given the visual complexity, it would be
necessary to perform chest CT scanning to detect a subtle
pneumonia. Mild cardiomegaly is longstanding. Tracheostomy
tube in standard placement. Left subclavian line ends in the
mid SVC. No pneumothorax.
CXR (___): In comparison with the study of ___, there is
little overall change. Monitoring and support devices remain in
place. Continued mild enlargement of the cardiac silhouette
with pulmonary edema and areas of atelectasis at both bases with
small effusions. In the appropriate clinical setting,
supervening pneumonia would have to be considered. Extensive
pleural calcifications along the hemidiaphragm and mediastinum
are unchanged.
NCHCT (___):
1. Interval evolution of hemorrhagic material in the right
thalamus with
decreased minimal layering hemorrhagic material in the occipital
horns of the lateral ventricles. No new intracranial
hemorrhage.
2. Slight increase in the degree of hydrocephalus compared to
the most recent CT from ___.
3. No acute large vascular territorial infarction.
NCHCT (___):
1. Continued evolution of the previous hemorrhage in the right
thalamus.
Slight increase in blood products in the occipital horns,
bilaterally;
however, this is likely due to redistribution. There is no
evidence of new acute hemorrhage.
2. Unchanged hydrocephalus.
NOTE ADDED IN ATTENDING REVIEW: Though unchanged over the short
interval,
there is substantially more ventricular dilatation, when
compared to the more remote studies, e.g. dated ___ and
___, particularly evident in the ventricular atria and
temporal horns. This finding should be correlated clinically and
may warrant treatment with EVD.
TEE (___): 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. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. No vegetation/mass
is seen on the pulmonic valve. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No evidence of endocarditis. Normal biventricular
systolic function.
EEG (___): This is an abnormal continuous EEG recording due
to runs of generalized periodic sharp waves with a triphasic
morphology at ___ Hz, particularly at the beginning of the
recording as there is a prolonged run, without evolution into
electrographic seizures. However, after the mid-morning, the EEG
improves as these sharp wave discharges become less frequent,
briefer in duration, and have a more blunted appearance. These
runs are also seen during patient stimulation, consistent with
stimulus-induced rhythmic, periodic, or ictal discharges
(SIRPIDs). These findings are indicative of highly irritable
cortex with potential for epileptogenesis. The background is
slow and disorganized activity consistent with a moderate
encephalopathy.
EEG (___):
1. Continued evolution of previous right thalamic hemorrhage
with progressive resorption of blood products in the region. No
evidence of new acute hemorrhage.
2. Unchanged mild hydrocephalus.
CXR (___): In comparison with the study of ___, there is
little change in the appearance of the tracheostomy and Dobbhoff
tube. Continued bilateral calcified pleural and diaphragmatic
plaques consistent with prior asbestos exposure. The
opacification at the right base is increasing, suggesting the
possibility of superimposed pneumonia on prior atelectatic
changes. Retrocardiac opacification is essentially unchanged.
EEG (___): This is an abnormal continuous EEG recording due
to the slow and disorganized background with bursts of
generalized delta frequency slowing indicative of a moderate
encephalopathy. There are infrequent independent left frontal
and right frontal regions, and generalized sharp waves,
indicative of focal and generalized cortical irritability. There
are no clear electrographic seizures. There is no significant
change throughout the study.
EEG (___): This is an abnormal continuous EEG recording due
to the slow and disorganized background with bursts of
generalized delta frequency slowing indicative a moderate
encephalopathy. There are infrequent independent discharges in
the left and right frontal/frontocentral, and left temporal
regions, as well as generalized sharp waves, indicative of
multifocal and generalized cortical irritability. There are no
clinical or electrographic seizures.
KUB (___): Two supine views of the abdomen show clear
distention of the colon, to a maximum diameter of 8 cm in the
hepatic flexure. There is also cluster of bowel loops in the
left mid and lower abdominal quadrant, at least some of which
appear to be small bowel, distended to caliber of 54 mm,
comparable to the dilatation of many more loops of small bowel
on ___. The finding is consistent with either a
paralytic ileus, or developing small-bowel obstruction needs
careful followup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY:PRN wheezing
2. Enalapril Maleate 20 mg PO BID
3. Doxazosin Dose is Unknown PO HS
4. Hydrochlorothiazide 25 mg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Metoclopramide 10 mg PO TID W/MEALS
Discharge Medications:
1. Doxazosin 4 mg PO HS
2. Nystatin Oral Suspension 5 mL PO QID:PRN Oral ___
3. Enalapril Maleate 20 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. Labetalol 600 mg PO TID
6. Heparin 5000 UNIT SC TID
7. Bisacodyl ___AILY
8. Multivitamins 1 TAB PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Pravastatin 40 mg PO DAILY
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/dyspnea
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing/dyspnea
13. Simethicone 40-80 mg PO QID:PRN gas
14. Lactulose 30 mL PO BID
15. Cyanocobalamin 50 mcg PO DAILY
16. Digoxin 0.125 mg PO DAILY
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
18. Linezolid ___ mg IV Q12H Duration: 5 Days
First day = ___
Last day = ___
19. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
ACUTE ISSUES:
1. Right basal ganglia hypertensive hemorrhage c/b hydrocephalus
requiring EVD placement
2. EVD associated meningitis and ventriculitis
3. Ventilator-associated pneumonia
4. Nonconvulsive seizures
5. Alcohol withdrawal
6. Ileus ___ opioid medications
7. Respiratory failure (s/p trach and PEG)
CHRONIC ISSUES:
1. Hypertension
2. Alcohol abuse
3. Cigarette smoking
4. COPD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with intraventricular and intraparenchymal hemorrhage.
Assess for interval change.
COMPARISONS: CT head of the same date from ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
There is extensive intraventricular hemorrhage involving predominantly right
lateral ventricle, extending into the frontal horn of the left lateral
ventricle as well as the third ventricle. No hemorrhage is seen within the
fourth ventricle. Intraventricular hemorrhage essentially unchanged in
distribution since the study obtained nine hours prior. There is an
intraparenchymal hemorrhage centered in the right basal ganglia and extending
into the thalamus, which now measures 2.5 x 1.5 cm, unchanged since prior.
There is surrounding vasogenic edema. No new focus of intracranial hemorrhage
is detected. There is no hydrocephalus. Basal cisterns are patent. The
sulci and ventricles are unchanged in size and configuration since prior and
are slightly prominent, likely age-related involutional changes. Confluent
hypodensities in periventricular, subcortical and deep white matter
distribution likely reflect sequela of small vessel ischemic disease. There
is moderate thickening of the ethmoid air cells. Otherwise, imaged paranasal
sinuses and mastoid air cells are well aerated. No acute fracture is
detected. The orbits are unremarkable.
IMPRESSION:
In comparison to study obtained nine hours prior, there is no significant
change in the intraventricular and intraparenchymal hemorrhage, as described
above. No new intracranial hemorrhage.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Elevated white blood cell count, evaluation for pneumonia.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Lateral pleural thickening with
calcifications. These project over the lung parenchyma and create the
appearance of nodular changes. Moreover, they limit the assessment of the
radiographic appearance of the lung parenchyma in both lower lung parts.
Presence of a subtle parenchymal abnormality, therefore, cannot be determined.
Moderate cardiomegaly without pulmonary edema. No evidence of pleural
effusions. No pneumothorax.
Radiology Report
INDICATION: Right thalamic hemorrhage with intraventricular extension.
Assess for interval change and evaluate for hydrocephalus.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material.
COMPARISON: CT head from ___.
FINDINGS: There is redemonstration of hemorrhage centered in the right
thalamus, slightly decreased in size compared to the prior CT from ___, measuring 2.8 x 1.5 cm, (2A:15) compared to 3.0 x 1.7 cm previously.
The degree of hemorrhagic material within the adjacent right ventricle,
extending into the third ventricle, is decreased. Previously seen minimal
layering hemorrhagic material within the occipital horn of the left lateral
ventricle is not appreciated on the current study. There is no new
intracranial hemorrhage. Vasogenic edema within the right basal ganglia,
adjacent to the site of hemorrhage, is similar in appearance. There is no
hydrocephalus, with unchanged size and configuration of the ventricles. There
is no acute large vascular territorial infarction. Periventricular white
matter hypodensities are a nonspecific finding is seen in the setting of
chronic small vessel ischemic disease. Mild prominence of the ventricles and
sulci is consistent with age-related involutional change. Calcifications are
seen in the bilateral cavernous carotid and vertebral arteries. The imaged
aspects of the orbits are unremarkable. There is scattered mucosal thickening
throughout bilateral ethmoidal air cells with opacification of a right
frontoethmoidal air cell. The remainder of the visualized portions of the
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. Slight interval decrease in the right basal ganglial hemorrhage, extending
into the thalamus. Degree of associated intraventricular hemorrhage within
the right lateral ventricle and third ventricle is also decreased. No new
intracranial hemorrhage.
2. No acute large vascular territorial infarction.
Radiology Report
INDICATION: History of right basal ganglia hemorrhage, now with persistent
downgaze. Evaluate for progression.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, and thin-section bone reconstruction algorithm
images were acquired.
COMPARISON: Multiple prior NECTs of the head, most recently on ___ at 8:30 a.m.
FINDINGS: Compared to most recent NECT of the head, hydrocephalus has
progressed considerably. There is now increasing dilatation of the temporal
horns of the lateral ventricles measuring up to 12 mm. Hemorrhage centered in
the right thalamus is unchanged and there are now layering blood products in
the occipital horn of the lateral ventricles. Surrounding vasogenic edema is
also unchanged. There also appears to be a small amount of blood products
within the fourth ventricle (2:7).
Subcortical and periventricular white matter hypodensities are again
consistent with chronic small vessel ischemic disease. There is no shift of
normally midline structures. There is no new focus of hemorrhage. There is
mucus retention in the left maxillary sinus. The remaining visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Worsening hydrocephalus compared to NECT from 8:30 a.m. Stable right
basal ganglia intraparenchymal hemorrhage with surrounding vasogenic edema.
Evolving blood products in the occipital horns of the lateral ventricles and
fourth ventricle.
2. No new area of hemorrhage.
Findings were communicated by Dr. ___ to ___ (neurology) by
phone at 12:20 a.m. on ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New intubation, assessment for tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has been
intubated. The tip of the endotracheal tube projects 7.6 cm above the carina.
The tube should be advanced by approximately 2-3 cm.
Otherwise, the radiograph is unchanged. Low lung volumes, the pleural
calcifications are again documented. Mild atelectasis at the left lung bases.
Minimal blunting of the left costophrenic sinus, potentially suggesting a
small left pleural effusion. No pneumothorax. Borderline size of the cardiac
silhouette.
Radiology Report
INDICATION: Intraparenchymal hemorrhage with worsening hydrocephalus. EVD
placement. Evaluation for interval change.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, thin section bone reconstruction algorithm
images were acquired.
COMPARISON: NECT of the head, ___, 2349 hours.
FINDINGS: In comparison to NECT of the head from less than two hours prior,
there is no significant interval change with the exception of a burr hole now
in the right lateral aspect of the frontal bone and small amount of
intracranial blood products (2:26). Again seen is large focus of hemorrhage
centered in the right thalamus with intraventricular extension. A
hydrocephalus with dilation of the temporal horns of the lateral ventricles is
unchanged. Blood products within the lateral ventricles and fourth ventricle
are also again noted.
Subcortical and periventricular white matter densities are consistent with
chronic small vessel ischemic disease. There is no shift of midline
structures. No new focus of hemorrhage is identified. With the exception of
mucus retention cyst in the left maxillary sinus the visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: Small focus of blood products adjacent to a right frontal burr
hole. Otherwise no significant interval change from NECT of the head obtained
less than two hours prior.
Radiology Report
INDICATION: Placement of EVD for hydrocephalus. Evaluation of drain
placement.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal and sagittal reformations were prepared.
COMPARISON: Multiple prior NECTs of the head, most recently on ___ at 136 hours.
FINDINGS: Right frontal EVD tip now terminates in the frontal horn of the
right lateral ventricle. Hydrocephalus is slightly decreased as evidence by
the temporal horns of the lateral ventricles are now slightly narrower than an
NECT-head from 90 minutes prior. Again seen is intraparenchymal hemorrhage
centered in the right thalamus extending into the lateral and fourth
ventricles. Surrounding vasogenic edema is unchanged. Small amount of
expected pneumocephalus is noted.
Subcortical and periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. No new focus of hemorrhage is
identified.
IMPRESSION:
1. Right frontal EVD placed with tip in the frontal horn of the right lateral
ventricle. Slight interval decrease in hydrocephalus compared to NECT
obtained 90 minutes prior.
2. Stable intraparenchymal hemorrhage centered in the right thalamus with
intraventricular extension.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Orogastric tube placement. Assessment.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received an
orogastric tube. Tip of the tube is not visible on the image, the sidehole
projects approximately 10 cm distal from the gastroesophageal junction. There
is no evidence of complications, notably no pneumothorax. Unchanged
appearance of the lung parenchyma. Unchanged position of the endotracheal
tube.
Radiology Report
INDICATION: Patient with history of right thalamic hemorrhage, assess for
interval change.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness.
FINDINGS:
There is an intraparenchymal hemorrhage centered in the right thalamus, which
now measures 2.2 x 1.4 cm, unchanged. There is surrounding vasogenic edema.
It is seen extending into ventricles involving the right lateral ventricle.
Trace amount of hemorrhagic fluid is seen layering in the occipital horn of
the left lateral ventricle as well as the fourth ventricle, unchanged. No new
focus of intracranial hemorrhage is detected. Again seen ventriculostomy
catheter with right frontal approach terminating in the right lateral
ventricle. The degree of hydrocephalus has slightly decreased since prior.
For example, the frontal horns now measure 3.2 cm, previously 3.7 cm (2:18).
The third ventricle now measures 9 mm, previously 14 mm (2:15). Basal
cisterns remain patent. Small amount of pneumocephalus overlying the right
frontal region is most likely related to ventriculostomy catheter placement,
unchanged. The globes are normal in appearance. No acute fracture is seen.
The imaged paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
In comparison to study obtained six hours prior, there is no significant
change in intraparenchymal hemorrhage involving the right thalamus.
Intraventricular hemorrhage is also unchanged in extent. The degree of
hydrocephalus has improved.
Radiology Report
AP CHEST, 3:07 A.M., ___
HISTORY: A ___ man with a past medical history of hypertension. New
basal ganglia hemorrhage.
IMPRESSION: AP chest compared to ___:
Large scale asbestos-related pleural calcification obscures much of the lungs,
particularly inferiorly. Comparing today's study to ___, previous mild
pulmonary edema has definitely improved, and atelectasis has worsened. Small
pleural effusions may now be present. Moderate cardiomegaly is unchanged. ET
tube is in standard placement and an upper enteric drainage tube ends in the
mid portion of a non-distended stomach. No pneumothorax.
Radiology Report
INDICATION: ___ male with new PICC.
COMPARISON: ___ at approximately 3 a.m.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in an upright position.
FINDINGS: Right PICC courses into the high right atrium. An esophageal
catheter courses below the diaphragm with tip out of view; side port projects
over the left upper quadrant. Endotracheal tube appears similarly positioned.
Pleural calcifications are again seen. Heavy continuous asbestos related
pleural calcification obscures both lower lungs and would hide subtle
findings. Small pleural effusions persist. No edema, pneumonia, or
pneumothorax is seen. Heart and mediastinal contours are stable with mild
cardiomegaly and aortic calcification.
IMPRESSION: Right PICC coursing into the high right atrium. Retracting 4.5
cm is recommended.
Original recommendation to retract the PICC 3 cm was discussed with ___
___ from the IV team by ___ by telephone at 10:05 a.m. on
___ at the time of initial review of the study. Per attending
radiologist, retracting 4.5 cm was recommended to ___ by
___ by telephone at 11:16 a.m. on ___ after attending
radiologist review. Since the catheter had already been retracted 3 cm, repeat
radiograph was recommended.
Radiology Report
REASON FOR EXAMINATION: Right basal ganglia hemorrhage, assessment for
interval change.
Portable AP radiograph was compared to ___ and demonstrates
extensive amount of calcified bilateral pleural plaques. Within the
limitations of the presence of those plaques, they potentially obscure
intraparenchymal process. No substantial change in bibasal areas of
atelectasis demonstrated. Right PICC line tip is at the cavoatrial junction.
Radiology Report
INDICATION: ___ man presents for evaluation after PICC
re-positioning.
COMPARISONS: ___ at 9:30 a.m.
TECHNIQUE: Single AP view of the chest.
FINDINGS: The right PICC terminates in the mid SVC. An esophageal catheter
courses below the diaphragm with the tip out of view. An esophageal catheter
courses below the diaphragm with the tip out of view; side port projects over
the left upper quadrant. The ET tube appears similarly positioned. Again
seen are heavy asbestos related pleural calcifications bilaterally, which may
obscure both lower lungs and hide subtle findings. Again seen are small
bilateral pleural effusions. No edema, pneumonia or pneumothorax is seen.
The heart and mediastinal contours are stable with evidence of mild
cardiomegaly and aortic calcification.
IMPRESSION: Right-sided PICC line terminates in the mid SVC.
These findings were discussed with ___ by Dr. ___ by telephone
at 3 p.m on the day of the exam.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with recent Dobbhoff placement, assess
placement.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Available for comparison is the next preceding similar
study obtained seven and a half hours earlier during the same day. During the
latest examination interval, a Dobbhoff line has been placed, seen to reach
well below the diaphragm with the tip located in the mid portion of the
stomach. Appearance of chest examination not significantly altered.
Radiology Report
AP CHEST, 6:11 A.M., ___
HISTORY: ___ man with intracerebral hemorrhage and right lower lobe
infiltrate.
IMPRESSION: AP chest compared to ___:
Patient has persistent moderate cardiomegaly and pulmonary vascular
engorgement. The lower lungs are largely obscured by heavy asbestos-related
pleural calcifications. There could be atelectasis or consolidation in the
right lower lobe, but the findings could actually be minimal. If the
determination of the presence of any consolidation is of high clinical
importance, I would recommend CT scanning.
Feeding tube passes into the stomach and out of view.
Radiology Report
HISTORY: New fever question pneumonia.
COMPARISON: One hundred ___.
FINDINGS:
Compared to the prior study. There is no significant interval change.
Radiology Report
HISTORY: ___ male with hydrocephalus.
TECHNIQUE: CT of the head without IV contrast.
COMPARISON: ___.
FINDINGS:
A right approach ventriculostomy catheter terminates in the frontal horn of
the right lateral ventricle, unchanged. The hydrocephalus is slightly
decreased in particularly when evaluating the occipital horn of the left
lateral ventricle. Intraparenchymal hemorrhage centered in the right thalamus
extending into the lateral ventricles is slightly smaller and the density is
evolving. The surrounding edema is stable. No new intraparenchymal bleed is
seen.
IMPRESSION:
1. Right frontal approach ventriculostomy catheter terminating in the frontal
horn of the right lateral ventricle. Minimal decrease in the amount of
hydrocephalus compared to the CT from 4 days prior upper
2. Evolving right thalamic hemorrhage without any evidence of new hemorrhage.
Radiology Report
HISTORY: Right ___ ganglia hemorrhage and hydrocephalus. Question
infiltrate.
COMPARISON: One hundred ___.
FINDINGS:
Again seen are calcified pleural plaques and diaphragmatic calcification.
There are bilateral lower lobe infiltrates that are worsened compared to the
study from the prior day. Heart size continues to be mildly enlarged.
Right-sided PICC line tip is at the cavoatrial junction. feeding tube tip is
off the film, at least in the stomach.
IMPRESSION:
Worsened appearance in both lower lobes.
Radiology Report
HISTORY: Worsening shortness of breath, check ETT.
___ at 0516 AM
FINDINGS:
There is a new ET tube with tip 5 cm above the carina. PICC line tip in the
distal SVC is unchanged. Pleural plaques are again visualized. There is
volume loss in the right midlung. Compared to the exam from earlier the same
day, aeration of lower lobes is slightly improved.
Radiology Report
HISTORY: ___ male with basal ganglia hemorrhage and EVD, now
requiring assessment for interval change status post re-intubation.
COMPARISON: Comparison is made with CT head from ___ and ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
FINDINGS: There is no evidence of new acute hemorrhage, edema, mass effect,
or infarction. The previously seen right intraparenchymal hematoma in the
right thalamus, which extends to the right lateral ventricle, demonstrates
evolving blood products with redistribution of the intraventricular blood.
___ edema is noted around the hematoma. A right approach
ventriculostomy catheter is seen again seen terminating in the frontal horn of
the right lateral ventricle. The ventricular size is unchanged from prior
exam. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. The patient is intubated. Visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The globes are
unremarkable
IMPRESSION:
1. Evolving right thalamic hematoma without evidence of new hemorrhage.
2. Ventricular size stable from prior exam.
Radiology Report
AP CHEST, 4:22 A.M., ___
HISTORY: Hypertension. Right basal ganglia hemorrhage.
IMPRESSION: AP chest compared to ___:
Heavy asbestos-related pleural calcifications obscure much of the lower lungs,
but nevertheless I can see that there is mild edema in the lower lungs and
small pleural effusions that were not present on ___ and have worsened
since ___. More confluent opacity at the base of the right lung could
be either atelectasis or early pneumonia and should be followed carefully. ET
tube tip is at the upper margin of the clavicles, no less than 10 cm from the
carina and should be advanced 4 cm for more secure seating. A feeding tube
ends in the upper stomach.
Dr. ___ was paged at 10 a.m.
Radiology Report
INDICATION: ___ man with abdominal distention.
TECHNIQUE: AP and left lateral decubitus images of the abdomen were obtained.
COMPARISON: None.
FINDINGS:
No free air. Multiple up to 3.5 cm dilated small bowel loops. Air in the colon
and rectum. These findings likely represent early small bowel obstruction,
less likely ileus.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New Dobbhoff placement, evaluation of tube position.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
Dobbhoff catheter. The course of the catheter is unremarkable, the tip of the
catheter projects over the mid part of the stomach. The other monitoring and
support devices are constant. Minimal improvement of the bilateral
predominantly basal parenchymal opacities. No new opacities. Unchanged
moderate cardiomegaly without overt pulmonary edema.
Radiology Report
HISTORY: NG tube placement.
FINDINGS: In comparison with the earlier study of this date, there is little
change except for the Dobbhoff tube, which extends at least to the upper
stomach where it passes out of view.
Otherwise little change.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Endotracheal tube placement.
COMPARISON: ___, 5:34.
FINDINGS: As compared to the previous examination, there is no substantial
change in position of the endotracheal tube. The tip of the tube currently
projects 6.6 cm above the carina and is located relatively high. Advancement
by 1-2 cm appears possible. Better delineated than on the previous
examination are the multiple pleural calcifications. The left medial
component of these calcifications mimics the presence of a pneumothorax (no
pneumothorax is clearly visible on the present examination).
Unchanged distribution and extent of the pre-existing parenchymal opacities.
Unchanged size of the cardiac silhouette.
Radiology Report
HISTORY: ___ male with right basal ganglia hemorrhage in the setting
of a hyperdense episode, now requiring assessment for interval change.
COMPARISON: Comparison is made with CT head from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
FINDINGS: This exam is somewhat limited due to motion artifact. There is no
evidence of new hemorrhage, edema, mass effect, or infarction. The previously
seen intraparenchymal hematoma in the right thalamus is unchanged from prior
exam. Intraventricular blood is again seen, unchanged from prior exam. The
right approach ventriculostomy catheter is again seen terminating in the
frontal horn of the right lateral ventricle. The ventricular size is
unchanged from prior exam. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No fracture is identified. There is a small retention cyst in the floor of
the left maxillary sinus. The other visualized paranasal sinuses, mastoid air
cells, middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Right thalamic hematoma, unchanged from prior exam.
2. Stable ventricular size from prior exam.
3. No new acute intracranial findings.
Radiology Report
AP CHEST, 5:59 ___ ON ___
HISTORY: ___ man with history of intracranial bleed. Assess NG tube
placement.
IMPRESSION: AP chest compared to ___:
New tracheostomy tube is in standard placement. There is no mediastinal
widening or pneumothorax. Combination of dependent edema and atelectasis in
lower lungs, largely obscured by heavy asbestos-related pleural calcification,
is unchanged over several days. Small bilateral pleural effusions are now
apparent. Moderate cardiomegaly is longstanding.
Right PIC line ends in the mid SVC, and both feeding and upper enteric
drainage tubes end in the mid stomach.
Radiology Report
HISTORY: ___ male with basal ganglia bleed with intraventricular
hemorrhage and clamping of EVD 48 hr ago, now requiring assessment for
hydrocephalus.
COMPARISON: Comparison is made with CT head from ___, and ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
FINDINGS: There is no evidence of new hemorrhage, edema, mass effect, or
infarction. The previously seen right thalamic hematoma demonstrates slightly
increased edema and appropriately evolving blood products. Intraventricular
blood is again seen, unchanged from prior exam. Ventricular prominence is
unchanged from prior exam. The right approach ventriculostomy catheter is no
longer seen terminating in the frontal horn of the right lateral ventricle,
but now appears to terminate just inside the skull. A small amount of blood
is seen along the tract where the EVD previously was positioned. The basal
cisterns appear patent and there is preservation of gray-white matter
differentiation.
No fracture is identified. A small retention cyst is again seen in the floor
of the left maxillary sinus. The other visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval change in position of the EVD, which is now positioned with the
tip just inside the skull. Once the EVD is completely removed, a followup CT
is recommended to insure that no catheter fragments remain intracranially.
2. Stable right thalamic hematoma with appropriately evolving blood products.
3. Stable ventricular size from prior exam.
4. No new acute intracranial findings.
These findings were communicated to ___ at 12:10 p.m. on ___.
Radiology Report
INDICATION: Recent EVD removal. Please assess ventricle size.
COMPARISON: Comparison is made to head CT performed same day.
TECHNIQUE: Non-contrast axial images were acquired through the brain.
Coronal and sagittal reformations were provided.
FINDINGS: Interval removal of right frontal approach ventriculostomy catheter
with a small amount of stable hemorrhage along the prior drain tract.
Ventricles demonstrate stable degree of hemorrhage and dilatation.
The known right thalamic hemorrhage is stable in size compared to prior study,
with unchanged degree of surrounding edema. No new hemorrhage is identified.
No new infarct or mass effect evident. Stable periventricular and subcortical
white matter hypodensities are most consistent with small vessel ischemic
disease.
The mastoid air cells and middle ear cavities are clear. Air-fluid levels are
noted within the ethmoid air cells. Stable mucoid-retention cysts are noted
in the left maxilla.
IMPRESSION:
1. Interval removal of right frontal approach ventriculostomy catheter with
stable degree of hemorrhage along the prior tract.
2. Stable right thalamic intraparenchymal hemorrhage with unchanged degree of
surrounding edema.
3. Stable ventricular size compared to prior exam. Stable degree of
intraventricular hemorrhage.
Radiology Report
HISTORY: Right basal ganglia infarction complicated by hydrocephalus status
post EVD drain placement and removal for interval change.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
COMPARISON: Multiple prior Head CT's with the most recent from ___.
FINDINGS:
Again noted is the right thalamic hemorrhagic infarct with surrounding edema,
stable in size. The ventricles remain stably dilated with hemorrhage layering
dependently within the occipital horns of bilateral lateral ventricles. There
has been interval removal of right frontal approach ventriculostomy catheter
and previously visualized small amount of hemorrhage along the drain tract
appears less conspicuous.
Otherwise, there is no evidence of new acute intracranial hemorrhage, edema,
large vessel territorial infarction, or shift of the midline structures.
Stable periventricular and subcortical white matter hypodensities are again
noted and suggestive of small vessel ischemic disease. No acute fractures are
identified. Again noted is opacification of the ethmoid air cells.
Previously noted mucous retentin cyst in the left maxillary sinus is not
included on this study. The remainder of the visualized mastoid air cells and
paranasal sinuses are clear.
IMPRESSION:
Little change in comparison to prior study with stable right thalamic
intraparenchymal hemorrhage with surrounding edema, as well as stable
ventricular size with dependent intraventricular hemorrhage.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with rising white blood
cell count in setup of prior pneumonia.
Portable AP radiograph of the chest was reviewed in comparison to ___.
A tracheostomy is in place. The Dobbhoff tube and the NG tube appear to be in
unchanged position. Multiple pleural plaques obscure the lung fields, and
within those limitations, no substantial change since the prior study has been
demonstrated to suggest interval development of new infectious process. Right
PICC line tip is at the level of low SVC.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Cerebral hemorrhage, tracheostomy, questionable pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of multiple pleural plaques, limiting the assessment of the lung parenchyma.
The areas of increased radiographic opacity over both lungs are constant and
have not changed since the prior examination. Normal appearance of the lung
parenchyma. No pleural effusions.
Radiology Report
HISTORY: ___ year old man with fever of unknown origin REASON FOR THIS
EXAMINATION: Any DVT?
COMPARISON: None available
FINDINGS:
Normal Doppler waveform with normal respiratory phasicity and normal
compressibility of the bilateral common femoral vein, and proximal greater
saphenous vein, proximal deep femoral vein, proximal, mid, and distal portions
of the femoral vein, popliteal vein, as well as the posterior tibial and
peroneal veins. No evidence of bilateral lower extremity deep venous
thrombosis.
IMPRESSION:
No evidence of bilateral lower extremity DVT.
Radiology Report
INDICATION: ___ male with hypertension and a right basal ganglia
intraparenchymal hemorrhage who presents for evaluation of free air given
abdominal distention.
COMPARISON: Chest radiographs from ___, 5:19 a.m. ___ and ___.
TECHNIQUE: Single AP portable view of the chest.
FINDINGS: The tracheostomy tube is in standard position. There is a
right-sided PICC line with the tip terminating in the mid SVC. The enteric
tube courses below the diaphragm with the tip beyond the scope of the film.
Again, multiple calcified pleural plaques overlie the lungs with unchanged
pleural thickening. There has been interval improvement of the left
retrocardiac opacity compared to the exam performed earlier this morning,
consistent with improving atelectasis. Non-specific opacity at the right lung
base is unchanged. No new focal consolidations are seen. The small bilateral
pleural effusions are stable. There is no pneumothorax. Moderate cardiomegaly
is longstanding. The hilar and mediastinal contours are otherwise normal.
There is no subdiaphragmatic free air.
IMPRESSION:
1. No evidence of subdiaphragmatic free air.
2. Interval improvement of left basilar atelectasis. No new focal opacities
identified.
3. Evidence of previous asbestos exposure.
Radiology Report
INDICATION: ___ man with hypertension and CVA, to rule out
obstruction.
COMPARISON: Abdomen radiograph, ___.
PORTABLE SUPINE ABDOMEN RADIOGRAPH: A Dobbhoff tube and nasogastric tube
terminate in the gastric body. Multiple dilated small bowel loops are seen
measuring up to 53 mm, slightly progressed since the prior study 38 mm. Air
is seen within a mildly distended colon to the level of the rectum. Supine
radiograph is limited for assessment of free air, within this limitation, no
free air is identified.
IMPRESSION: Diffusely dilated small and large bowel loops, likely represent
ileus.
Radiology Report
INDICATION: ___ man with right basal ganglia hemorrhage, now febrile
and has leukocytosis and abdominal distention.
COMPARISON: Abdomen radiograph done earlier today at 9:47 a.m.
TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained
without intravenous contrast. Venous contrast was deferred due to the
patient's elevated creatinine of 1.5. Oral contrast was administered for this
study.
FINDINGS: Bilateral extensive pleural calcifications, predominantly in the
diaphragmatic pleura relate to prior asbestos exposure. Trace bilateral
pleural effusions and dependent atelectasis is noted in both lungs. Extensive
coronary arterial calcifications are seen in the imaged portion of the heart.
There is no pericardial effusion.
A nasogastric tube and a Dobbhoff tube end in the gastric body. Within the
limitations of a non-contrast study, the liver and gallbladder are normal. A
linear high-density material is seen within the body of the pancreas (2:29),
of unclear etiology. There are no CT findings to suggest acute pancreatitis.
A 6 mm rounded density overlying the left renal hilum (2:31) may represent a
calcified left renal artery aneurysm. Simple right renal cortical cyst in the
lower pole measures 6.4 cm. No hydronephrosis or renal stones are identified.
The abdominal aorta has moderate-to-severe atherosclerotic calcification
without aneurysmal dilation. No significant retroperitoneal or mesenteric
lymphadenopathy is seen.
The administered oral contrast is seen within the stomach and proximal small
bowel loops. There is mild diffuse dilation of the small bowel loops,
maximally measuring 4.2 cm. No focal transition point is identified. The
large bowel is unremarkable. No free fluid or air is seen.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: Small amount of air in the urinary
bladder relates to the Foley catheter. The prostate and seminal vesicles are
unremarkable. A rectal catheter is in place. Extensive sigmoid colonic
diverticulosis is seen, without evidence of acute diverticulitis. No
significant pelvic lymphadenopathy or free fluid is seen.
BONES AND SOFT TISSUES: Moderate degenerative changes are seen in the lumbar
spine, worse at the L2-L3 level where there is moderate reduction of the disc
height with endplate sclerosis and large osteophyte formation. There is mild
compression of the superior endplate of L4 vertebral body. No focal lytic or
sclerotic bone lesion is identified.
IMPRESSION:
1. Mildly dilated fluid filled small bowel loops, without a focal transition
point. Findings most suggestive of ileus.
2. No acute abdominal pathology, especially no evidence of pancreatitis.
3. Extensive bilateral diaphragmatic calcifications, suggestive of prior
asbestos exposure.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intraparenchymal hemorrhage, leukocytosis, evaluation for
pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of relatively extensive calcified pleural plaques. Therefore, assessment of
the lung parenchyma is severely limited. The patient presents unchanged
evidence of mild cardiomegaly. The monitoring and support devices are
unchanged, except for the right PICC line that has been removed in the
interval. No pneumothorax.
Radiology Report
HISTORY: Central catheter.
FINDINGS: In comparison with the earlier study of this date, there has been
placement of a left subclavian catheter that extends to about the junction of
the brachiocephalic and superior vena cava. The remainder of the study is
essentially unchanged.
Radiology Report
AP CHEST, 4:17 AM, ___
HISTORY: ___ man with hypertension. Brain hemorrhage. Increased
sputum after tracheostomy.
IMPRESSION: AP chest compared to ___ through ___:
Heavy pleural calcification due to asbestos exposure obscures large areas in
the lower lungs, but symmetric increase in radiodensity in the lung bases is
probably due to pulmonary edema. But given the visual complexity, it would be
necessary to perform chest CT scanning to detect a subtle pneumonia. Mild
cardiomegaly is longstanding. Tracheostomy tube in standard placement. Left
subclavian line ends in the mid SVC. No pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with intraparenchymal
hemorrhage, tracheostomy, increased work of breathing.
Portable AP radiograph of the chest was reviewed in comparison to ___ obtained at 04:17 a.m.
Tracheostomy is unchanged in appearance. Dobbhoff tube passes below the
inferior margin of the field of view. Widespread calcified asbestos plaques
are unchanged as well as partially imaged basal opacities with no evidence of
new abnormality has developed.
Radiology Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: ___ male patient with respiratory failure, status post
tracheostomy, ICH with new PICC. Asess PICC line. Contact name: ___
___.
FINDINGS: AP single view of the chest has been obtained with patient in
semi-upright position. Comparison is made with the next preceding similar
study obtained seven hours earlier during the same day.
On the present examination, the patient is moderately tilted to the left. The
tracheostomy cannula remains in appropriate position. Again identified is the
previously described left subclavian approach central venous line seen to
terminate in the mid portion of the SVC. The new left-sided PICC line assumes
a similar location and it is advanced through the mediastinum. It terminates
overlying the superior mediastinum some 1.5 cm above the level of the carina.
The location is similar as the termination point of the previously placed left
subclavian approach central venous line. The fact that it does not project to
the right of the trachea is explained by the patient's left-sided tilted
position. If further advancement of the PICC line is possible, it is
recommended to do so. If not and good blood flow is obtained, the line could
be used safely. There is no evidence of pneumothorax and the lung findings
have not undergone any significant interval change.
___ was paged at ___ at 4:15 p.m.
Radiology Report
HISTORY: CVA, to assess for change.
FINDINGS: In comparison with the study of ___, there is little overall
change. Monitoring and support devices remain in place. Continued mild
enlargement of the cardiac silhouette with pulmonary edema and areas of
atelectasis at both bases with small effusions. In the appropriate clinical
setting, supervening pneumonia would have to be considered.
Extensive pleural calcifications along the hemidiaphragm and mediastinum are
unchanged.
Radiology Report
CLINICAL HISTORY: Right thalamic hemorrhage, now has fevers. Evaluate for
pneumonia.
CHEST AP:
COMPARISON FILM: ___.
Compared to the prior chest x-ray, there has been some clearing of both bases.
The position of the various support lines and tubes is unchanged.
Extensive pleural calcification is again noted.
IMPRESSION: Clearing of both bases.
Radiology Report
CLINICAL HISTORY: Right thalamic hemorrhage, nasogastric tube placed.
Check position.
CHEST PA: Two chest tubes are seen within the esophagus running into the
stomach, both in satisfactory position. Extensive pleural calcifications are
again noted. There has been no significant change since the prior chest x-ray
otherwise.
IMPRESSION: Two nasogastric tubes present both with tips in the stomach.
Radiology Report
HISTORY: Right thalamic hemorrhage complicated by hydrocephalus, status post
external ventricular drainage placement, now status post removal. Evaluate
for interval change.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material.
COMPARISON: CT head from ___.
FINDINGS:
There has been continued evolution of a right thalamic hemorrhage with
interval partial resorption of blood products and unchanged surrounding
vasogenic edema. Minimal leftward shift of the midline structures is not
significantly changed. There has been a slight increase in the degree of
hydrocephalus compared to the most recent CT from ___, with the
transverse measurements across the frontal horns of the lateral ventricles at
the level of the caudate heads measuring 4.0 cm compared to 3.8 cm previously
and the transverse measurement of the ___ ventricle now 1.6 cm compared to 1.2
cm previously. Minimal hemorrhagic material layering in the occipital horns
of the lateral ventricles has decreased. There is no new intracranial
hemorrhage or acute large vascular territorial infarction. Periventricular
and subcortical white matter hypodensities are a nonspecific finding can be
seen in the setting of chronic small vessel ischemic disease. Calcifications
are seen in the bilateral cavernous carotid and vertebral arteries. The
orbits are unremarkable. Mucosal thickening is seen throughout bilateral
ethmoidal air cells. There is also opacification of scattered bilateral
mastoid air cells. Minimal mucosal thickening is seen in the right maxillary
sinus. There is also minimal mucosal thickening and a mucous retention cyst
in the left maxillary sinus. Skin staples overlie the right frontal region,
subjacent to which is a burr hole, presumably created for passage of external
ventricular drainage catheter, which is no longer present.
IMPRESSION:
1. Interval evolution of hemorrhagic material in the right thalamus with
decreased minimal layering hemorrhagic material in the occipital horns of the
lateral ventricles. No new intracranial hemorrhage.
2. Slight increase in the degree of hydrocephalus compared to the most recent
CT from ___.
3. No acute large vascular territorial infarction.
Radiology Report
CLINICAL HISTORY: Status post intracranial hemorrhage and tracheostomy.
CHEST
There has been no significant change since the prior chest x-ray. The left
pleural effusion is again noted. Some upper zone re-distribution is again
noted on the left side.
IMPRESSION: No significant change. Some cardiac failure still present.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ chest radiograph.
FINDINGS: Tracheostomy tube and nasogastric tube remain in place. Side port
of nasogastric tube is at or just proximal to the expected location of the GE
junction and could be advanced a few centimeters for standard positioning.
Feeding tube terminates below the diaphragm with tip beyond the field of view.
Extensive bilateral calcified pleural plaques are again demonstrated, in
keeping with prior asbestos exposure. Bibasilar lung opacities appear similar
to the recent chest radiograph, and remain partially obscured by the adjacent
pleural disease. Small pleural effusions appear similar to the prior
radiograph.
Radiology Report
HISTORY: Right basal ganglia parenchymal hemorrhage with change in mental
status, with increase in hydrocephalus on CT on ___ evidence for
change in "brain pathology" (sic).
TECHNIQUE: Contiguous axial images are obtained through the brain. No
contrast was administered.
COMPARISON: ___ CT head and ___ CT head.
FINDINGS:
Again seen is the right thalamic hemorrhage with resorption of blood products
and surrounding vasogenic edema, unchanged compared to yesterday's study.
Minimal leftward shift of the midline structures is not changed. The degree
of hydrocephalus is unchanged compared to yesterday's study with transverse
measurement across the frontal horns of the lateral ventricles at the level of
the caudate heads measuring 4.0 cm. There is evidence of blood products in
the occipital horns bilaterally, which is slightly increased compared to
yesterday's study however this may be due to redistribution. There is no new
acute hemorrhage. Again seen are periventricular and subcortical white matter
hypodensities likely from chronic small vessel ischemic disease. Bilateral
cavernous carotid and vertebral artery calcifications are seen. Mucosal
thickening in the ethmoid air cells, maxillary sinuses, and mastoid air cells
are again seen. Right frontal burr hole is again seen.
IMPRESSION:
1. Continued evolution of the previous hemorrhage in the right thalamus.
Slight increase in blood products in the occipital horns, bilaterally;
however, this is likely due to redistribution. There is no evidence of new
acute hemorrhage.
2. Unchanged hydrocephalus.
NOTE ADDED IN ATTENDING REVIEW: Though unchanged over the short interval,
there is substantially more ventricular dilatation, when compared to the more
remote studies, e.g. dated ___ and ___, particularly evident in the
ventricular atria and temporal horns.
This finding should be correlated clinically and may warrant treatment with
EVD.
Radiology Report
HISTORY: Ventricular drain and prior intracranial hematoma, now with CSF
analysis concerning for infection.
COMPARISON: Head CT dated ___ and ___
TECHNIQUE:
Multi planar MR images were acquired through the brain including sequences
acquired prior to and following the uneventful intravenous administration of
gadolinium based contrast.
FINDINGS:
The examination is somewhat degraded by patient motion. Nevertheless, note is
made of dependent fluid fluid levels in the occipital horns of both lateral
ventricles, demonstrating abnormally slow diffusion. Postcontrast images also
demonstrate abnormal enhancement along the ependymal margins of both occipital
horns (series 15, image 11). Small foci of abnormally slow diffusion are also
seen along the surface of the brain, likely subarachnoid in location overlying
the cerebellar hemispheres bilaterally, as well as within the left sylvian
fissure (series 702, image 17).
In the lateral aspect of the thalamus on the right, corresponding to the site
of the known previous hematoma is a 2.5 x 1.9 cm T1 hyperintense focus. There
is no definite evidence of post-contrast enhancement, though assessment is
difficult due to the intrinsic signal hyperintensity. Gradient echo images
reveal a rim of susceptibility artifact surrounding this area. DWI imaging
demonstrates signal hyperintensity corresponding to this focus.
There is no new intracranial hemorrhage. Ventricles are unchanged in size and
configuration. Primary intracranial flow voids are normal. There is no new
space-occupying mass. The tract from a prior right frontal ventricular drain
is noted.
IMPRESSION:
1. Abnormally slow diffusion seen dependently in the occipital horns of the
lateral ventricles bilaterally, with overlying abnormal ependymal enhancement.
These findings, in conjunction with the provided history, are highly
concerning for bilateral ventriculitis, with appearing went material
dependently in both lateral ventricles.
2. Punctate foci of peripheral slow diffusion in the supra and infratentorial
brain as described above, likely representing subarachnoid seeding of the
infectious intraventricular debris already described.
3. Right lateral thalamic hematoma. Overall, this focus demonstrates an
appearance consistent with hematoma, and the possibility of superimposed
infection is not excluded, though there are no specific signs to definitively
suggest this.
These results were discussed via telephone by Dr. ___ with Dr. ___ at
21:45 on ___ and by Dr. ___ with Dr. ___ at 08:45 on ___
Radiology Report
HISTORY: ___ year old man with abdominal distension, leukocytosis, fever, ?
developing ascites vs. intraabdominal infection REASON FOR THIS EXAMINATION:
assess for intra-abdominal infection. Portable study .
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Normal echotexture of the liver parenchyma, without evidence of focal liver
mass or intrahepatic biliary ductal dilatation. Hypertrophic appearance of
the left hepatic lobe again noted. There appears to be dilation of the
hepatic veins, question cardiac congestion. Partially visualized head, body,
and tail of pancreas appear unremarkable. Partially visualized aorta and IVC
appear unremarkable. Pulsatile hepatopetal flow within the main portal vein
consistent with right heart failure. Normal-appearing common bile duct
measuring 3 mm in diameter. No evidence of right hydronephrosis. Simple
appearing right renal cortical cyst measuring 6.0 x 6.0 x 6.5 cm, without
flow, appears unchanged. Normal-appearing left kidney without hydronephrosis.
Normal-appearing spleen measuring 8.2 cm in length. No evidence of ascites.
IMPRESSION:
No ultrasound evidence of intra-abdominal fluid collections. Dilation of the
hepatic veins with pulsatile portal venous flow, indicative of right heart
failure. Simple right renal cortical cyst unchanged.
Radiology Report
REASON FOR EXAM: Persistent leukocytosis, patient with tracheostomy.
Comparison is made with prior study, ___.
There is stable mild-to-moderate cardiomegaly. Tracheostomy tube is in
standard position. Enteric tube tip is out of view below the diaphragm.
Extensive bilateral calcified pleural plaques are again seen. There are no
interval changes of bibasilar lung opacities and probably small left effusion.
Radiology Report
HEAD CT WITHOUT CONTRAST
INDICATION: ___ male with right basal ganglia/thalamic hemorrhage,
with hydrocephalus and EVD-associated meningitis, encephalitis. Evaluate for
interval change.
COMPARISON: Multiple prior head CTs, most recent on ___. Head
MR on ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without administration of IV contrast.
DLP: 891.93 mGy-cm.
CTDI: 51.69 mGy.
FINDINGS: A 2.5 x 1.9 cm hypodensity in the right thalamic region extending
into the posterior limb of the internal capsule as well as the body of the
caudate nucleus (2:16) is redemonstrated and compatible with evolving
hemorrhagic CVA. Compared with prior exam, there is interval decrease in
internal hyperattenuation suggesting continued resorption of blood products.
Otherwise, there is no new focus of hemorrhage, edema, mass, mass effect, or
large territorial infarction. The ventricles are slightly dilated but
unchanged from prior exam. Periventricular white matter changes are
compatible with chronic small vessel ischemic disease. The basal cisterns are
patent and there is preservation of gray-white matter differentiation in the
non-affected areas of the brain.
No fractures are identified. There is a mucus retention cyst in the left
maxillary sinus, but otherwise, the paranasal sinuses, mastoid air cells and
middle ear cavities are clear. A nasal tube is present in the left nasal
passage. There is no facial or cranial soft tissue abnormality.
Atherosclerotic calcifications of the vertebral arteries and carotid siphons
are present.
IMPRESSION:
1. Continued evolution of previous right thalamic hemorrhage with progressive
resorption of blood products in the region. No evidence of new acute
hemorrhage.
2. Unchanged mild hydrocephalus.
Radiology Report
PORTABLE CHEST FILM, ___ AT 07:17
CLINICAL INDICATION: ___ status post Dobbhoff tube placement, assess
position.
Comparison to prior study dated ___ at 08:49.
IMPRESSION:
1. Interval placement of a Dobbhoff feeding tube with the tip projecting over
the expected location of the stomach. A tracheostomy tube remains in place.
Bilateral calcified pleural and diaphragmatic plaques are seen consistent with
prior asbestos exposure. Overall, bibasilar patchy opacities are stable. No
focal airspace consolidation is seen to suggest pneumonia. No evidence of
pulmonary edema or pneumothorax.
Radiology Report
HISTORY: Tracheostomy with brain abscess.
FINDINGS: In comparison with the study of ___, there is little change in the
appearance of the tracheostomy and Dobbhoff tube. Continued bilateral
calcified pleural and diaphragmatic plaques consistent with prior asbestos
exposure. The opacification at the right base is increasing, suggesting the
possibility of superimposed pneumonia on prior atelectatic changes.
Retrocardiac opacification is essentially unchanged.
Radiology Report
HISTORY: Cerebral bleed, to assess for pulmonary edema.
FINDINGS: In comparison with the study of ___, there again are
opacifications at the bases consistent with atelectasis and effusion, though
supervening pneumonia would have to be considered in the appropriate clinical
setting. Plaquing again is consistent with asbestos exposure and Dobbhoff
tube and tracheostomy tube remain in place.
Radiology Report
HISTORY: ___ male patient with right PICC line placement.
COMPARISON: Prior chest radiograph from ___.
TECHNIQUE: Portable semi-erect chest radiograph.
FINDINGS:
The right PICC line is seen within the right jugular vein, beyond the upper
margin of the image. The remainder of the findings remain the same as to
those seen on chest radiograph from ___ at 5:03 a.m.
IMPRESSION: Right PICC line within right jugular vein.
These findings were discussed with ___ venous access nurse by Dr.
___ telephone on ___ at 10:05, time of discovery.
Radiology Report
PICC LINE EXCHANGE/REPOSITIONING
INDICATION: Malposition of indwelling PICC line.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ Dr. ___ the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was
advanced through the indwelling right arm PICC line, and subsequently into the
SVC under fluoroscopic guidance. The old PICC line was then removed and a
peel-away sheath was then placed over the guidewire. A new double-lumen PICC
line measuring 41.5 cm in length was then placed through the peel-away sheath
with its tip positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a
new double-lumen PICC line. Final internal length is 41.5 cm, with the tip
positioned in the SVC. The line is ready to use.
Radiology Report
INDICATION: Intubated with intraparenchymal hemorrhage complicated by
meningitis, now with respiratory desaturation and tachypnea, here to evaluate
for interval changes.
COMPARISON: Multiple prior chest radiographs dating back to ___,
most recently ___.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: A Dobbhoff feeding tube is seen coursing below the diaphragm with
the elongated tip in the gastric fundus, which could be advanced further into
the stomach. A tracheostomy is in place. A right PICC line is repositioned
now with the tip terminating in the mid-to-low SVC. Opacification of the
bilateral bases greater on the left than the right is minimally increased from
the most recent prior study compatible with small pleural effusions and
atelectasis. Diaphragmatic calcifications and pleural calcified plaques are
again noted consistent with asbestos exposure. The cardiac silhouette remains
moderately enlarged. The mediastinal contours are within normal limits. The
pulmonary vasculature appears engorged but stable.
IMPRESSION:
1. Persistent pulmonary vascular congestion, small pleural effusions and
slightly increased bibasilar atelectasis on the left greater than the right.
2. Improved positioning of right PICC with tip terminating in the mid-to-low
SVC.
Radiology Report
AP CHEST, 4:17 A.M. ON ___
HISTORY: ___ man with fluid overload.
IMPRESSION: AP chest compared to ___:
Moderately severe pulmonary edema has recurred, since earlier improvement
between ___. It is more pronounced today than on ___.
Moderate cardiomegaly is longstanding. Heavy asbestos-related pleural
calcification obscures large areas of the lower lungs. Small-to-moderate
right pleural effusion has increased. Tracheostomy tube in standard
placement. Right PIC line ends in the low SVC. No pneumothorax.
Radiology Report
HISTORY: ___ male with history of right basal ganglia hemorrhage,
complicated by hydrocephalus status post EVD complicated by meningitis and
ventriculitis with persistently poor mental status. Evaluation for
hydrocephalus, stroke or other interval change.
COMPARISON: Comparison is made to multiple prior studies including most
recent noncontrast CT of the head from ___ and MRI of the head
from ___.
FINDINGS:
Again seen is a hypodensity in the right lateral thalamus, which is not
significantly changed since the prior study and is in keeping with evolving
hematoma and resorption of blood products (2:16). The size of the ventricles
is unchanged since the prior study and there is no mass effect or shift of
midline structures. There is no new focus of hemorrhage, edema, mass, mass
effect or large vascular territory infarction. The previously seen
periventricular white matter changes are likely due to chronic small vessel
ischemic disease. Basal cisterns are patent and there is preservation of the
gray-white matter differentiation in non-affected areas of the brain.
Skin staples are noted over the right frontal scalp. No fractures are
identified. There is re- demonstration of a left maxillary mucous retention
cyst and there is scattered opacification with air-fluid levels in the
bilaterally mastoid air cells, otherwise the paranasal sinuses are clear.
IMPRESSION:
1. Right lateral thalamic hypodensity, representing evolving hematoma and
resorption of blood products.
2. There is no new intracranial hemorrhage.
3. Unchanged mild hydrocephalus.
Radiology Report
AP CHEST 5:04 A.M. ___
HISTORY: A ___ man with a right basal ganglia hemorrhage, after
tracheostomy tube, unable to tolerate CPAP. Is there pulmonary edema or
pneumonia.
IMPRESSION: AP chest compared to ___ through ___:
Mild-to-moderate pulmonary edema and pulmonary vascular engorgement have
improved since ___. Small left pleural effusion and moderate
cardiomegaly persist. Extent of bibasilar consolidation difficult to assess
given the overlying heavy asbestos-related calcified pleural plaque.
Conceivably, a lateral conventional chest radiograph would be helpful in
determining how much of the abnormality at the lung bases, particularly the
right, is due to pleural effusion and how much due to lower lobe atelectasis
or consolidation.
Tracheostomy tube is turned, tip abutting the left wall. Right PIC line ends
in the mid SVC. No pneumothorax.
Radiology Report
ABDOMEN, ___
HISTORY: ___ man after PEG tube. Distended abdomen.
IMPRESSION: Two supine views of the abdomen show clear distention of the
colon, to a maximum diameter of 8 cm in the hepatic flexure. There is also
cluster of bowel loops in the left mid and lower abdominal quadrant, at least
some of which appear to be small bowel, distended to caliber of 54 mm,
comparable to the dilatation of many more loops of small bowel on ___.
The finding is consistent with either a paralytic ileus, or developing
small-bowel obstruction needs careful followup.
Dr. ___ was paged at 4:30 p.m. and we discussed the findings by
telephone at 4:45pm.
Radiology Report
HISTORY: Basilar ganglia hemorrhage in the setting of hypertensive episode
status post tracheostomy now bacteremic. Evaluate fluid status.
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: Multiple chest radiographs ranging from ___ through
___.
FINDINGS:
Moderate cardiomegaly is unchanged from ___. Engorgement of the
pulmonary vasculature is unchanged from immediate prior exam consistent with
moderate pulmonary edema with persistent bilateral small pleural effusions and
adjacent bibasilar atelectasis. The right PICC is unchanged position with the
tip projecting over the mid SVC and a tracheostomy tube is in place. Again
appreciated are scattered calcified pleural plaques. There is no
pneumothorax.
IMPRESSION:
Unchanged moderate pulmonary edema with persistent small pleural effusions and
bibasilar atelectasis.
Radiology Report
INDICATION: ___ male with respiratory failure, fluid overload, and
difficulty weaning off vent to trach. Question pulmonary edema versus
effusion.
COMPARISON: Multiple prior exams, most recently ___.
FINDINGS: Single semi-erect frontal view of the chest demonstrates unchanged
tracheostomy and a right PICC in standard position. The heart remains
prominent. Perihilar vascular engorgement and moderate pulmonary edema is
little changed. There is persistent bilateral small pleural effusion
associated with atelectasis. Calcified pleural plaques are seen in the basal
pleura bilaterally.
IMPRESSION: No significant interval change since one day ago of moderate
pulmonary edema and bilateral pleural effusions.
Radiology Report
HISTORY: Tracheostomy and meningitis.
FINDINGS: In comparison with study of ___, there is little interval change.
Continued enlargement of the cardiac silhouette with elevated pulmonary venous
pressure, evidence of pleural effusions with a possible area of loculation at
the right base laterally. Patchy opacification in the right mid zone is
unchanged. Pleural plaquing is again seen bilaterally with calcification in
the hemidiaphragmatic region.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEAD BLEED
Diagnosed with BRAIN HEM NEC W/O COMA, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS
temperature: 98.0
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 183.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | ___ yo RH man with h/o HTN, COPD, EtOH and tobacco abuse who
developed an acute sense of dysequilibrium followed by a fall,
found to have right basal ganglia hypertensive hemorrhage (in
setting of SBP 200) with intraventricular extension. Course c/b
hydrocephalus requiring EVD, EVD-associated
meningitis/ventriculitis, EtOH withdrawal, paralytic ileus, AFib
with RVR, and respiratory failure, and hypoproliferative anemia.
# NEURO:
(1) BASAL GANGLIA HEMORRHAGE C/B HYDROCEPHALUS: Patient admitted
to Neuro ICU for close monitoring and blood pressure control s/p
hemorrhage. On admission his neuro exam was notable for mild
inattentiveness and subtle left hemiparesis but was otherwise
intact. On HD#1 he was persistently hypertensive, requiring
nicardepine drip, and developed EtOH withdrawal which was
treated with CIWA protocol. On HD #2 he developed Parinaud
syndrome (sustained downward gaze suggestive of midbrain
compression). Head CT showed new hydrocephalus. EVD was
emergently placed at the bedside by Neurosurgery, intubated
prior to procedure to enable adequate sedation. Neuro exam
improved transiently for a couple of days (able to open eyes and
follow commands), then deteriorated again with no changes seen
on NCHCT to suggest worsening hydrocephalus. He was then found
to have EVD-associated meningitis/ventriculitis and
nonconvulsive seizures (see below) which likely accounted for
his deterioration.
Likely etiology of patient's hemorrhage was hypertension in
setting of SBP 200 on admission. MRI showed no evidence of
underlying mass lesion. For treatment of his HTN, he first
received nicardepime gtt in ICU, then was transitioned to PO
meds with good BP control.Antihypertensives on discharge are
amlodipine, labetalol, enalapril and doxazosin.
(2) EVD-ASSOCIATED MENINGITIS/VENTRICULITIS: On HD #13, EVD was
discontinued. CSF cultures from that date were negative.
Following EVD removal he had a superficial CSF leak for which
Neurosurgery placed staples. He then had mild worsening
hydrocephalus noted on head CT for which repeat EVD was not
required. Several days after EVD removal patient began to spike
high fevers. Initial concern was for VAP based on CXR, but he
subsequently developed meningismus and hyperreflexia. Empiric
meningitic doses of vancomycin/cefepime were started given
concern for meningitis. LP on HD #23 showed 2900 WBCs (72%
PMNs), glucose 17, protein 503. He was empirically switched to
Linezolid/Daptomycin/Ertapenam to treat for all resistant
organisms, as blood cultures from the same day were found to be
growing VRE. CSF cultures subsequently also grew out VRE and
strep viridans, so he was narrowed to Linezolid alone. MRI
showed ventriculitis and possible pus in the ventricles. Per ID
recs, he will complete a 3 week course of Linezolid (last day =
___ given presence of ventriculitis. Repeat LP on HD #30
showed improved CSF profile (WBC 33, protein 119) and cultures
grew coag negative staph, likely contaminent per ID. He had
multiple head CTs following this given risk for arachnoid
granulation obstruction (in setting of CSF pus and IVH) causing
worsening hydrocephalus, which were all stable.
(3) POSSIBLE NONCONVULSIVE SEIZURES: In the setting of
meningitis/ventriculitis EEG was performed to determine if
seizures were contributing to patient's poor clinical exam. It
showed GPEDs and triphasic waves consistent with severe cortical
irritability, likely ___ his underlying infection. Keppra 1g BID
was started. It was gradually weaned during hospitalization
(while monitoring intermittently on EEG) as the seizures were
thought secondary to his infection which is resolving, and out
of concern it was contributing to sedation. Keppra was stopped
on HD #28, and his mental status continued to improve.
# PULM:
(1) RESPIRATORY FAILURE: Patient was intubated in setting of EVD
placement on HD#2. He subsequently could not be weaned off
ventilator and required tracheostomy on HD #11. He was gradually
weaned to CPAP, but was noted to become tachypneic to ___ on
attempts to wean to trach mask toward end of his ICU course.
Etiology of resp failure is likely multifactorial. He has COPD
and asbestosis making his baseline respiratory status
suboptimal. He has diastolic CHF ___ HTN, and had persistent
mild pulmonary edema requiring frequent Lasix boluses. Finally,
critical illness neuromyopathy may be contributing (although he
never received steroids or prolonged neuromuscular blockage): he
does have proximal muscle weakness and although his reflexes are
preserved this can be seen in critical illness neuromyopathy. On
discharge he was tolerating ___ hour trials on trach mask before
developing respiratory fatigue. He will need intensive pulmonary
rehab on discharge. He should also receive Lasix 40mg IV with
blood transfusions.
(2) VAP: Patient developed e/o PNA on HD #4 which resolved with
10-day course of Vanc/Cefepime.
# CARDIAC:
(1) AFib with RVR: Patient intermittently in AFib with RVR
during hospitalization (has no known history of AFib). He was
started on digoxin 0.125mg daily for treatment. His AFib was
thought secondary to his critical illness. Can consider
discontinuing digoxin as an outpatient.
(2) HTN: Poorly controlled, SBPs up to 200 on admission. TTE
shows EF 55%, mild symmetric LVH. HTN responded to nicardepime
gtt and then PO amlodipine, labetalol, enalapril and doxazosin
(home med). BP well controlled in 130s-140s for majority of
hospitalization.
(3) HLD: Initially held home pravastatin in setting of ICH, then
restarted. LDL 61.
# ID:
(1) EVD-associated meningitis/ventriculitis: See above. CSF cx
grew out VRE and strep viridans. Treating with 3 week course of
Linezolid ___ IV q12 hrs, last day = ___.
(2) VRE bacteremia: Found to have VRE bacteremia on HD #20. TEE
negative for infective endocarditis. Surveillance cultures all
returned negative. Initially treated with broad spectrum abx
(___), then narrowed to Linezolid when cx grew
VRE.
# HEME:
(1) HYPOPROLIFERATIVE ANEMIA: Patient had gradual HCT drop from
39 -> mid ___ during hospitalization, then nadired at 21 one
week after starting Linezolid (which causes bone marrow
suppression). Retic index 0.33%, iron studies c/w anemia of
chronic disease, negative serial stool guaiacs and hemolysis
workup, B12/folate WNL. Etiology of anemia is multifactorial.
He has underlying bone marrow suppression from chronic EtOH,
critical illness and superimposed Linezolid toxicity (though of
note typically does not cause pure RBC aplasia). He required
transfusion of 4 units pRBC during hospitalization, and expect
will have ongoing transfusion requirement while on Linezolid.
Transfusion threshold: HCT<25. He should receive Lasix 40mg IV
boluses with blood transfusions.
# GI:
(1) ILEUS: Patient developed ileus during ICU stay secondary to
opioids and prolonged immobilization. This improved gradually
with holding opioids and then uptitrating bowel regimen. On
discharge his abdomen is softly distended with positive bowel
sounds, and he is passing flatus and stool.
(2) NUTRITION: Open G tube was placed on ___ without
complication and tube feeds started after 24 hours.
# PSYCH:
(1) EtOH withdrawal: Patient went into EtOH withdrawal on HD#2
which resolved on CIWA scale with valium. He was started
empirically on B12, folate and a multivitamin for nutrition.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Left shoulder pain
Major Surgical or Invasive Procedure:
Incision and drainage of abscess
History of Present Illness:
The patient is a ___ year old female with history of diabetes
mellitus, hypertension, and left rotator cuff repair requiring
hardware (___) with revision (___) who presented to the ER
with worsening left shoulder pain (___) since the ___
before admission. The patient reported decreased range of motion
in that extremity with erythema overlying the area since the day
before admission. The patient reported chills with subjective
fevers. The patient had been taking Tylenol twice daily for the
past few days before admission for the pain with minimal relief.
She denied any recent trauma or insect bites to area.
In the ED, initial vital signs were T99.0 P60 BP147/62 R24
96%. Initial labs did not demonstrate a leukocytosis, and chem-7
was appropriate except for hyperglycemia, and her lactate was
2.0. Blood cultures were pending. Ortho was consulted who did
not believe this represented a septic joint and recommended soft
tissue I&D. Bedside ultrasound demonstrated two loculated
subcutaneous lesions that were fluctuant on exam. She underwent
I&D in the ER. Little puss was present, but the wound was packed
and cultures were sent. Vitals on transfer were 97.8 66 155/78
18 95%.
Past Medical History:
NIDDM
Hypertension
Hyperlipidemia
Depression
Gout
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Physical Exam on Admission:
Vitals: T99.1 P88 BP138/62 R20 94%O2
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LUE with decreased ROM in all directions, area of
erythema over shoulder with 1-1.5cm incision packed, minimal
warmth.
Neuro: CNs2-12 intact, motor function grossly normal
Physical Exam on Discharge:
VS98.2 174/81 68 18 97%ra
___ 217, 272, 220
MILD ERYTHEMA WELL W/IN BORDERS OF MARKING ON L SHOULDER.
CLEAN DRY DRESSING IN PLACE
FULL RANGE OF MOTION OF LIMB
Pertinent Results:
Shoulder XR (___): No acute fracture or dislocation.
___ 12:30PM BLOOD WBC-9.8 RBC-4.36 Hgb-12.3 Hct-37.7 MCV-86
MCH-28.2 MCHC-32.6 RDW-15.3 Plt ___
___ 06:25AM BLOOD WBC-9.3 RBC-4.42 Hgb-12.2 Hct-38.1 MCV-86
MCH-27.7 MCHC-32.0 RDW-15.1 Plt ___
___ 12:30PM BLOOD Glucose-265* UreaN-14 Creat-0.8 Na-136
K-4.3 Cl-98 HCO3-27 AnGap-15
___ 06:25AM BLOOD Glucose-207* UreaN-14 Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-26 AnGap-17
___ 06:50AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
___ 12:46PM BLOOD Lactate-2.0
___ 12:30 pm BLOOD CULTURE
**FINAL REPORT ___
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 ___. ___ ON ___ AT
0530.
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 3:58 pm ABSCESS TB RECEIVED SPECIMEN AS SWAB.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NO MYCOBACTERIA ISOLATED.
Medications on Admission:
Unable to obtain information regarding preadmission medication
at this time. Information was obtained from webOMR.
1. Artificial Tears ___ DROP BOTH EYES DAILY
2. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
3. Docusate Sodium 100 mg PO BID
4. Atorvastatin 20 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
Hold for SBP<100
6. Paroxetine 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h:prn wheezing
9. Allopurinol ___ mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atenolol 100 mg PO DAILY
Hold for SBP<100
12. Clonazepam 0.5 mg PO QHS
Hold for sedation
13. clotrimazole-betamethasone *NF* ___ % Topical BID
14. GlipiZIDE 10 mg PO DAILY
15. Hydrochlorothiazide 25 mg PO DAILY
Please hold for SBP<100
16. MetFORMIN (Glucophage) 1000 mg PO BIDWM
17. Valsartan 320 mg PO DAILY
Hold for SBP<100
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
Hold for SBP<100
3. Artificial Tears ___ DROP BOTH EYES DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 100 mg PO DAILY
Hold for SBP<100
6. Atorvastatin 20 mg PO DAILY
7. Clonazepam 0.5 mg PO QHS
Hold for sedation
8. Docusate Sodium 100 mg PO BID
9. Hydrochlorothiazide 25 mg PO DAILY
Please hold for SBP<100
10. Omeprazole 20 mg PO DAILY
11. Paroxetine 20 mg PO DAILY
12. Valsartan 320 mg PO DAILY
Hold for SBP<100
13. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
14. clotrimazole-betamethasone *NF* ___ % Topical BID
15. GlipiZIDE 10 mg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BIDWM
17. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation q6h:prn wheezing
18. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*16 Tablet Refills:*0
19. Cephalexin 500 mg PO Q6H Duration: 10 Days
RX *cephalexin 250 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
RX *cephalexin 500 mg 1 tablet(s) by mouth four times a day Disp
#*32 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis:
Abscess
Secondary Diagnoses:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left shoulder repair with swelling and redness.
TECHNIQUE: Left shoulder, 3 views.
COMPARISON: ___.
FINDINGS:
3 soft tissue anchors are again demonstrated within the left humeral head. No
acute fracture or dislocation is seen. Degenerative spurring of the
acromioclavicular joint is again noted. Small well corticated ossific density
is demonstrated lateral to the greater tuberosity, likely reflecting
heterotopic ossification. The visualized left lung is clear.
IMPRESSION:
No acute fracture or dislocation.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: L SHOULDER ABCESS
Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF ARM
temperature: nan
heartrate: 66.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | The patient is a ___ F h/o diabetes, hypertension, and left
rotator cuff repair requiring hardware with ___ days of left
shoulder pain, found to have subcutaneous abscess.
.
ACUTE ISSUES
#Left shoulder abscess
Patient found to have subcutaneous abscess in left shoulder. An
I&D in ER was performed, the abscess was packed, and wound
cultures were sent. She was started on vancomycin. An xray was
not significant for osteomyelitis, and did not appear to involve
joint or hardware. Orthopedics was consulted in the ER and
concluded that her joint was not involved. Her exam was
significant for and erythematous region wtih decreased ROM. No
fevers were reported. She was continued on vancomycin while
inpatient and wound care was continued. She was transitioned to
bactrim and keflex and discharged with prescriptions. Home
nursing care was established for help with wound care.
.
#Positive blood culture
One of the two sets of initial blood cultures from the emergency
room were positive for coagulase negative staphylococcus with
two distinct morphological colonies. Initially, the patient was
continued on vancomycin before speciation occurred. The positive
culture was thought to be a contaminant.
.
CHRONIC ISSUES
#Diabetes mellitus:
Patient with history of diabetes, on glipizide and metformin at
home. She was found to be yperglycemic in the ER. The patient's
metformin and glipizide were held, sliding scale insulin was
started, and the patient was given a diabetic diet.
.
#Hypertension:
Patient with history of hypertension. Her systolic pressures
were in the 140-150s in ER. She remained symptomatic. She was
continued on her home-dose amlodipine, atenolol, valsartan, and
HCTZ.
.
#Depression:
Patient with history of depression, denied symptoms or SI at
time of admission. She was continued on home-dose clonazopam and
paroxetine.
.
TRANSITIONAL ISSUES
The patient was discharged with a follow-up appointment with her
PCP and wound care by home nursing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking woman with DM2, HTN, HLD, and
chronic low back pain who presents with shortness of breath of 1
day duration, palpitations, and lower back pain. Her dyspnea
began 1 day prior to admission while walking to the supermarket.
Dyspnea is exertional, improves with rest. Now cannot climb a
flight of stairs without feeling short of breath. No associated
chest pain, although she endorses palpiatations. Denies
orthopnea or PND. Associated right sided headache without
blurry vision, paresthesias or focal weakness. She denies
nausea, diaphoresis, or lightheadedness. No cough, sputum
production, wheezing, fever, chills, nightsweats, or sick
contacts. Denies history of blood clots, recent travel, lower
extremity edema, or extended immobility.
Patient brought her medications with her but does not have any
of her antihypertensives including HCTZ, lisinopril, metoprolol,
or amlodipine. She reports she is waiting for a refill and is
not sure if her son picked it up yet. Per her pharmacy,
antihypertensives were last filled ___ with a 90 day supply.
In the ED, initial vitals: 97.6 ___ on unknown
amount of oxygen. Labs notable for WBC 5.6 with 6.1%
eosinophils, HCT 40 with MCV 78, normal BNP 249, normal chem 7,
d-dimer 1759, lactate 1.5, clean UA. Received nitroglycerin SL
and 40mg IV lasix. Vitals prior to transfer: 97.4 83 189/103 20
95% on unknown amount of oxygen.
On the floor, patient was tachpneic to ___ saturating 99% on
RA. She denies shortness of breath at rest. No chest pain,
palpitations. Overall she feels improved since receiving nitro
and lasix in the ED. Right sided headache, now improved, w/o
focal neurological signs.
ROS:
(+)per HPI,
(-)denies fever, chills, night sweats, vision changes,
rhinorrhea, congestion, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, change in bowel movements,
hematochezia, or dysuria.
Past Medical History:
Hypertension
Diabetes mellitus
Hyperlipidemia
Back pain, shoulder pain, knee pain
Memory loss
Social History:
___
Family History:
Uncle (mother's brother) w/ diabetes. Other family members with
hypertension, diabetes, pain. Mother died from hypertension
complications.
Physical Exam:
Admission Physical Exam:
VS 98.5, 181/86 73 26 99%RA
GEN Alert, oriented, no acute distress, lying on back in bed
HEENT MMM sclera anicteric OP clear
NECK supple no LAD
PULM b/l basilar crackles R>L, no wheezes
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO Strength grossly intact, follows comands, moves
extremities appropriately
SKIN no ulcers or lesions
Discharge Physical Exam:
VS 98.5, 127/60 55 20 99%RA
I: ? O: BRP, 200uop (7am)
GEN Alert, oriented, no acute distress, lying on back in bed
HEENT MMM sclera anicteric OP clear
NECK supple no LAD
PULM b/l basilar crackles intervally improved since ___, no
wheezes
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO Strength grossly intact, follows comands, moves
extremities appropriately
SKIN no ulcers or lesions appreciated
Pertinent Results:
Admission Labs:
___ 10:18AM BLOOD WBC-5.6 RBC-5.19 Hgb-12.9 Hct-40.5
MCV-78* MCH-24.8* MCHC-31.8 RDW-14.4 Plt ___
___ 10:18AM BLOOD Neuts-46.2* ___ Monos-5.4
Eos-6.1* Baso-1.5
___ 10:18AM BLOOD Plt ___
___ 10:18AM BLOOD Glucose-73 UreaN-9 Creat-0.6 Na-139 K-4.5
Cl-102 HCO3-28 AnGap-14
___ 10:18AM BLOOD cTropnT-<0.01 proBNP-249
___ 10:18AM BLOOD D-Dimer-1759*
___ 10:18AM BLOOD TSH-0.53
___ 10:28AM BLOOD Lactate-1.5
Discharge Labs:
___ 05:00AM BLOOD WBC-6.1 RBC-4.78 Hgb-12.7 Hct-37.3
MCV-78* MCH-26.5* MCHC-33.9 RDW-14.7 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-140* UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-100 HCO3-27 AnGap-16
___ 05:00AM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD Calcium-9.8 Phos-5.5* Mg-2.1
Additional Studies:
Portable Chest X-Ray ___
FINDINGS:
Single portable AP upright chest radiograph demonstrates low
lung volumes.
Heart is mildly enlarged, but the cardiomediastinal silhouette
is otherwise
unremarkable. Lungs demonstrate mild basilar atelectasis
without focal
consolidation. No pleural effusion or pneumothorax.
IMPRESSION: No evidence of pneumonia.
Chest CTA w/wo contrast ___
FINDINGS: Pulmonary arteries are well opacified to the
subsegmental level
without filling defect to suggest pulmonary embolism. Thoracic
aorta is of
normal caliber without aneurysms or dissection. There is no
axillary, mediastinal, or hilar lymphadenopathy. Heart is
normalin size and there is no pericardial effusion. The
previously seen mesomyocardial hypodensity is not well
visualized on this study. Trachea is midline and airways are
patent to subsegmental levels. Lungs demonstrate bibasilar
atelectasis, but no focal areas of consolidation. A 2-mm nodule
in the right upper lobe is unchanged compared to the prior study
(3:46). There is no pleural effusion. There is no
pneumothorax. Diffuse enlargement of the thyroid is again seen,
but partially imaged. Limited view of the upper abdomen is
unremarkable.
IMPRESSION: No evidence of pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
hold for SBP <90
2. Atorvastatin 40 mg PO DAILY
3. GlipiZIDE XL 5 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
hold for SBP <90
6. Lisinopril 40 mg PO DAILY
hold for SBP <90
7. TraMADOL (Ultram) 50 mg PO TID PRN pain
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP <90 or HR <60
10. Vitamin D ___ UNIT PO DAILY
11. Acetaminophen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Atorvastatin 40 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. TraMADOL (Ultram) 50 mg PO TID PRN pain
5. Vitamin D ___ UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
10. GlipiZIDE XL 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Hypertensive Emergency
Flash Pulmonary Edema
Secondary Diagnosis
Hypertension
Hyperlipidemia
Chronic low back pain
Diabetes Mellitus
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 and CHF, evaluate for pneumonia.
COMPARISON: ___.
FINDINGS:
Single portable AP upright chest radiograph demonstrates low lung volumes.
Heart is mildly enlarged, but the cardiomediastinal silhouette is otherwise
unremarkable. Lungs demonstrate mild basilar atelectasis without focal
consolidation. No pleural effusion or pneumothorax.
IMPRESSION: No evidence of pneumonia.
Radiology Report
INDICATION: Dyspnea and elevated D-dimer. Evaluate for pulmonary.
COMPARISON: CTA chest from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained from the thoracic inlet
through the upper abdomen after rapid infusion of 100 cc Omnipaque intravenous
contrast. Coronal and sagittal reformatted images were generated.
DLP: 313 mGy-cm.
FINDINGS: Pulmonary arteries are well opacified to the subsegmental level
without filling defect to suggest pulmonary embolism. Thoracic aorta is of
normal caliber without aneurysms or dissection.
There is no axillary, mediastinal, or hilar lymphadenopathy. Heart is normal
in size and there is no pericardial effusion. The previously seen
mesomyocardial hypodensity is not well visualized on this study. Trachea is
midline and airways are patent to subsegmental levels. Lungs demonstrate
bibasilar atelectasis, but no focal areas of consolidation. A 2-mm nodule in
the right upper lobe is unchanged compared to the prior study (3:46). There
is no pleural effusion. There is no pneumothorax.
Diffuse enlargement of the thyroid is again seen, but partially imaged.
Limited view of the upper abdomen is unremarkable.
IMPRESSION: No evidence of pulmonary embolism.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.6
heartrate: 72.0
resprate: 20.0
o2sat: 100.0
sbp: 209.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old woman with a history of diabetes mellitus
type 2, hypertension, hyperlipidemia, chronic low back pain who
presented with exertional dyspnea, headache, and palpitations in
the setting of hypertensive emergency after returning home from
___ 6 days prior to admission without having taken her blood
pressure medications for greater than 2 months. In the emergency
department, her blood pressure was 209/85 with tachypnea and
palpitations. A chest X-ray showed possible pulmonary edema at
the lung bases. A D-dimer was elevated to 1759. Her lactate was
1.5 and she had a clean urinalysis. A CT-Angiogram was
performed out of concern for a pulmonary embolism and was found
to be negative with the exception of bibasilar atelectasis. She
was treated with 40mg intravenous lasix and nitroglycerin with
improvement in her breathing status and blood pressure
downtrending to the sysloic 180's. On the floor, she was given
an additional 20mg intravenous lasix and restarted on two of her
home blood pressure medications, metoprolol and lisinopril. Her
amlodipine and hydrochlorothiazide was held due to concern for
dropping her blood pressure to quickly given she had likely been
hypertensive for several months. Her blood pressure stabilized
in the systolic 140's. Her labs were unremarkable throughout her
admission including 2 sets of cardiac enzymes. Her shortness of
breath improved overnight with improvement of her bibasilar
crackles, resolution of her headache, and no additional
palpitations. Her ambulatory oxygen saturation was 97-99% on
room air without reported dyspnea. There were no recorded events
on the telemetry. She remained afebrile with stabilization of
vital signs and tolerating PO without difficulty. She was
discharged on her home hydrochlorathiazide and metoprolol with
close primary care follow-up to restart her other home blood
pressure medications as needed. She was counseled about the need
to continue with her medications at home and when she travels
internationally.
All other chronic medical conditions were managed without
complications. She remained full code throughout her admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old female who presents with recurrent
cellulitis and abscess. She had a tattoo performed at a friend's
house ___ weeks ago. She then bumped her arm. She then noticed
pain and swelling in the arm 1 week ago. 2 days ago she
presented to ___ where the abscess was drained and she was
placed on Keflex. She took the Keflex qid but her arm remained
red. No fevers or chills at home but ? febrile at ___.
___. No other PMH. When she was "little" she had an abscess on
her head. Denies poor compliance with Keflex although she
reported that it made her feel sick.
.
VS at triage:6 |98 |91 |117/62 |16 |100% RA
Medications given: ceftriaxone/vancomycin/1L NS
Confirmed with ___ resident that bedside US did not demonstrate
abscess.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI- no weight loss
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: [X] All normal
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [+] Per HPI
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:
Abscess on head as a child
Obesity, unspecified
Snoring
Headache(784.0)
Depressed
Knee Pain
Assault
Depressive disorder, not elsewhere classified
Moderate major depression
Non smoker
Cellulitis and abscess
Leukocytosis
Social History:
___
Family History:
Her mother has anemia. She does not know about her dad's medical
history
Physical Exam:
Admission exam:
Vitals: T 98.6 P 59 BP 112/66 RR 18 SaO2 99% on RA
GEN: NAD, comfortable appearing
HEENT: ncat anicteric MMM + lip piercing
Remote Tattoo behind her R ear done by the same provider
___
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
EXTR:no c/c/e 2+pulses
R dorsal forearm with raised erythematous 3 x/5 cm area which
appears as though there could be an abscess underneath. No clear
flutuance appreciated. Site of previous I and D C/D/I. Erythema
and swelling tracking the dorsal aspect of the hand which is
very tender to palpation. 2+ radial pulse appreciated.
Pain with flexion and extension of wrist joint
DERM: as above
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
Pertinent Results:
Admission labs:
___ 09:19PM LACTATE-1.2
___ 09:00PM GLUCOSE-88 UREA N-15 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
___ 09:00PM estGFR-Using this
___ 09:00PM WBC-11.1* RBC-4.68 HGB-13.7 HCT-41.8 MCV-89
MCH-29.3 MCHC-32.8 RDW-12.9 RDWSD-42.0
___ 09:00PM NEUTS-51.4 ___ MONOS-5.1 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-5.70 AbsLymp-4.42* AbsMono-0.56
AbsEos-0.29 AbsBaso-0.05
___ 09:00PM NEUTS-51.4 ___ MONOS-5.1 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-5.70 AbsLymp-4.42* AbsMono-0.56
AbsEos-0.29 AbsBaso-0.05
Imaging:
Right forearm ultrasound:
No drainable fluid collection. 9 x 8 x 6-mm region of focal
fluid in the right
distal lateral forearm with surrounding marked cellulitis,
corresponding to
the area of clinical concern.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cephalexin 500 mg PO Q6H
2. Ibuprofen 800 mg PO Q6H:PRN pain
Discharge Medications:
1. Ibuprofen 800 mg PO Q6H:PRN pain
2. Mupirocin Ointment 2% 1 Appl TP DAILY
apply daily with dressing changes
RX *mupirocin 2 % apply to incision daily with dressing change
daily Refills:*0
3. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 7 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
4. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman with R forearm abscess s/p I and D. Area
present concerning for abscess. Informal US in ED negative for abscess but
would like a formal US. // Please evaluate for abscess.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right distal lateral forearm in the area of clinical concern.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
In the right distal lateral forearm, corresponding to the area of clinical
concern. A hypoechoic, ill-defined region in the subcutaneous tissue with
internal echogenic debris measures approximately 0.9 x 0.6 x 0.8 cm with
peripheral hypervascularity. In the soft tissues surrounding this area, there
is a moderate amount of soft tissue edema and inflammation.
IMPRESSION:
No drainable fluid collection. 9 x 8 x 6-mm region of focal fluid in the right
distal lateral forearm with surrounding marked cellulitis, corresponding to
the area of clinical concern.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abscess
Diagnosed with Cellulitis of right upper limb
temperature: 98.0
heartrate: 91.0
resprate: 16.0
o2sat: 100.0
sbp: 117.0
dbp: 62.0
level of pain: 6
level of acuity: 4.0 | ___ year old healthy female who initially presented to ___
___ with R forearm abscess in the setting of recent home
tattoo s/p I&D and Reflex in the ___ 2 days prior to
admission, now presenting with worsening R forearm and wrist
pain/swelling. There was concern for MRSA given a history of a
boil as a child and lack of improvement with Reflex. She was
started on dual antibiotic therapy with IV vancomycin and
ceftriaxone. Her leukocytosis and erythema improved overnight.
Her ultrasound showed no drainable fluid collection. Hand
surgery was consulted due to nearby swelling of the right hand
just proximal to the MCP joints. They recommended ongoing IV
antibiotics and elevation. Arm improved and ultimately she was
tranitioned to oral antibiotics.
HIV and HBV serologies and HCV VL were sent due to history of
tattoo performed at her 'friend's house' and: HIV negative. HBV
serologies not c/w infection, and HCV VL pending at time of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p mechanical fall ___ steps
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ on Coumadin with left lateral lower rib pain and dyspnea
after mechanical fall down 15 carpeted steps. Presented
ambulatory with abrasion to left orbit, EOEM intact no vision
changes. No midline neck tenderness
Past Medical History:
hypertension, hyperlipidemia, permanent
atrial fibrillation, COPD, bilateral detached retina, status
post
surgery, bilateral cataracts, chronic right ankle pain, chronic
bilateral knee pain, lower extremity edema, varicose veins and
possible vasovagal syncope. Otherwise, as above, right
bundle-branch block, hypertension, hyperlipidemia.
Family History:
non-contributory
Physical Exam:
On admission physical Exam:
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: left sided rib tenderness
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
___: No petechiae
Discharge Physical Exam:
VS: 98.2 97.9 93 100/91 18 95 RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, non- tender, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 09:00PM ___ 09:00PM ___ PTT-32.6 ___
___ 09:00PM PLT COUNT-165
___ 09:00PM WBC-12.3* RBC-4.73 HGB-16.6 HCT-46.0 MCV-97
MCH-35.1* MCHC-36.1 RDW-12.5 RDWSD-44.7
___ 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:00PM LIPASE-20
___ 09:00PM estGFR-Using this
___ 09:00PM UREA N-23* CREAT-1.0
___ 09:04PM HGB-17.2 calcHCT-52
Radiology Report
INDICATION: Trauma.
TECHNIQUE: Supine AP view of the chest.
COMPARISON: Chest radiograph ___ at 16: 40 and CT torso ___ at 17:40
FINDINGS:
Lung volumes are low. Cardiac silhouette size remains moderately enlarged.
Widening of the superior mediastinal contour is likely due to low lung volumes
and AP supine technique. Crowding of bronchovascular structures is present
without overt pulmonary edema. Streaky bibasilar airspace opacities likely
reflect atelectasis with a trace left pleural effusion noted. No pneumothorax
is detected on this supine exam. Multiple minimally displaced left-sided rib
fractures are again noted.
IMPRESSION:
Low lung volumes. Bibasilar atelectasis and small left pleural effusion.
Multiple left-sided minimally displaced rib fractures, as seen on prior CT.
Radiology Report
INDICATION: ___ year old man with rib fractures // atelectasis, effusions,
PTX?
TECHNIQUE: AP lateral
FINDINGS:
As compared to chest radiograph from 1 day prior, pulmonary vascular
congestion has improved. Increasing retrocardiac opacity can be worsening
edema. Small left effusion has increased. Minimally displaced left rib
fracture are difficult to appreciate. No definite pneumothorax.
IMPRESSION:
No visualized pneumothorax. Slight increase in left lower lobe effusion.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old man s/p fall with wrist pain // ? fracture ?
dislocation
TECHNIQUE: Three views left wrist.
COMPARISON: None available
FINDINGS:
There are severe degenerative changes at the thumb carpometacarpal joint and
moderate degenerative changes at the thumb metacarpophalangeal joint. No
fracture or dislocation seen. No destructive lytic or sclerotic bone lesions.
IV tubing projects over the radius on the frontal views.
IMPRESSION:
No acute bony injury seen.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ___ year old man s/p fall with left shoulder pain // fracture?
dislocation?
TECHNIQUE: Three views left shoulder
COMPARISON: Left humerus radiographs ___
FINDINGS:
No fracture or dislocation seen. There are mild to moderate degenerative
changes of both the glenohumeral and acromioclavicular joints. No destructive
lytic or sclerotic bone lesion seen. No radiopaque foreign body or soft
tissue calcification. Visualized portions of the left lung demonstrate low
lung volumes, likely due to suboptimal inspiratory effort.
IMPRESSION:
No acute bony injury seen. Degenerative changes of both the glenohumeral and
acromioclavicular joints.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fall (on) (from) other stairs and steps, initial encounter
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | The patient transferred from OSH to the ED after ___hest x-ray showed left ___ minimally-displaced
rib fracture. He has been admitted to the regular floor for
conservative management, pain control, respiratory toileting and
ambulating.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed will with PO oxycodone and
Dilaudid hydromorphone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was on Regular diet, which was well
tolerated fine. Patient's intake and output were closely
monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
Patient has been evaluated by ___ service and they recommended
Rehab facility to gain his strength before he can go home.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bendamustine
Attending: ___.
Chief Complaint:
Rash on left neck
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ CLL (s/p recent initiation of Venetoclax and on monthly
Rituximab), HTN/HLD, pAFIB (no a/c) who presented with 4 days of
left-sided neck discomfort and rash. He was in USOH until ___
days prior to admission, when he noticed an "aggravating"
stiffness on the left side of his neck. ___ days later, he
noticed a small rash over the region. The morning of admission,
he found the rash grew in area to cover most of the left side of
his neck. He therefore
presented to the ED for further evaluation.
He denied any pain or burning sensation over the rash. He denies
any other symptoms including hearing pain, ear pain, vision
changes. No fevers/chills, SOB, abdominal pain, N/V/D. He
reports he had chicken pox as a child (around age
___. He has never received shingles vaccine.
Past Medical History:
Chronic lymphocytic leukemia diagnosed ___, s/p treatment with
6 cycles of Rituxan/Fludaribine, then Bendamustine ___ x 3
cycles, then Ibrutinib ___, Chlorambucil ___, and started
Venetoclax ___
HTN
HLD
GERD
Previous EtOH Abuse per records
Colonic adenoma
Fracture of cervical vertebrae
Erectile dysfunction
pAFIB (not on anticoagulation due to prior intracranial
hemorrhage)
CLL as above
Intracranial hemorrhage/stroke due to ibrutinib
Social History:
___
Family History:
No known history of hematologic malignancy
Maternal uncle with prostate cancer
Physical Exam:
General: Well appearing elderly gentleman. Resting in bed
comfortably
Neuro:
Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally,
resists eye opening ___, hearing intact to finger rub b/l,
palate
elevates symmetrically, tongue midline, shoulder shrug ___
Motor:
___ handgrip bilaterally
___ plantar and dorsiflexion
Sensation intact to light touch over UE and ___
Alert and oriented x 3
HEENT: Oropharynx clear, no lesions. Sclera anicteric, no
conjunctival irritation. No rashes involving the ear
Cardiovascular: bradycardic, regular, soft systolic murmur best
appreciated at RUSB
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended
Extr/MSK: No peripheral edema, no rashes
Skin: Multiple crusted over lesions over the left neck
predominantly in C3
dermatome but extending into C2 and C4 regions. Not draining,
nontender to palpation.
Access: R POC site is c/d/I and nontender to palpation
Pertinent Results:
ADMISSION LABS:
___ 10:20AM GLUCOSE-101* UREA N-10 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 10:20AM ALT(SGPT)-19 AST(SGOT)-23 CK(CPK)-61 ALK
PHOS-90 TOT BILI-0.3
___ 10:20AM WBC-19.1* RBC-4.12* HGB-12.1* HCT-37.3*
MCV-91 MCH-29.4 MCHC-32.4 RDW-12.5 RDWSD-41.4
___ 10:20AM NEUTS-7* BANDS-0 LYMPHS-89* MONOS-3* EOS-1
BASOS-0 ___ MYELOS-0 AbsNeut-1.34* AbsLymp-17.00*
AbsMono-0.57 AbsEos-0.19 AbsBaso-0.00*
DISCHARGE LABS:
___ 05:04AM BLOOD WBC-20.8* RBC-4.03* Hgb-11.8* Hct-35.6*
MCV-88 MCH-29.3 MCHC-33.1 RDW-12.4 RDWSD-39.8 Plt ___
___ 05:04AM BLOOD Neuts-18* Bands-0 Lymphs-74* Monos-8
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-3.74
AbsLymp-15.39* AbsMono-1.66* AbsEos-0.00* AbsBaso-0.00*
___ 05:04AM BLOOD Glucose-114* UreaN-10 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-24 AnGap-14
___ 6:04 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
Reported to and read back by ___ ___ 11:13AM.
POSITIVE FOR VARICELLA ZOSTER.
Viral antigen identified by immunofluorescence.
IMAGING:
CT Neck w/ and w/o contrast (___):
1. Extensive left cervical lymphadenopathy - may be reactive in
etiology or secondary to patient's neoplasm. Continue clinical
follow up is recommended.
2. Patent bilateral internal jugular veins.
3. 1 cm hypodense right thyroid nodule.
4. Fracture of the right lamina of C5, of uncertain chronicity.
5. Approximately 4 mm left upper lobe pulmonary nodule.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cialis (tadalafil) 20 mg oral DAILY:PRN
2. Pantoprazole 40 mg PO Q24H
3. Allopurinol ___ mg PO DAILY
4. Venetoclax 400 mg PO DAILY
5. Gemfibrozil 600 mg PO BID
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 2 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
Disp #*3 Tablet Refills:*0
2. ValACYclovir 1000 mg PO Q8H Duration: 8 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times daily
Disp #*25 Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Cialis (tadalafil) 20 mg oral DAILY:PRN
5. Gemfibrozil 600 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Venetoclax 400 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Herpes zoster infection
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: ___ yo M PMHx CLL, here with zoster, having fevers// Eval for PNA
Eval for PNA
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Mild cardiomegaly stable. Lungs clear. Normal vasculature. No pleural
abnormality. New right supraclavicular central venous infusion catheter ends
at the level of the superior cavoatrial junction. No mediastinal widening.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ yo M PMHx CLL on venetoclax and rituximab who p/w herpes
zoster over C3 dermatome, now with low grade fever, swelling and palpable
"cord" in left neck. Please assess for clot vs abscess // Venous clot vs
abscess in left neck
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 27.7 cm; CTDIvol = 8.0 mGy (Body) DLP = 215.4
mGy-cm.
Total DLP (Body) = 215 mGy-cm.
COMPARISON: CTA head and neck ___.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
A soft tissue density within the left neck extends from approximately the
level of the C2 vertebral body to the C7 vertebral body (05:38) (02:32).
There is no surrounding fat stranding or suggestion of abscess.
The salivary glands enhance normally and are without mass or adjacent fat
stranding.A hypodensity of the right thyroid measures approximately 1 cm
(02:56).Multiple cervical and axillary lymph nodes are prominent (for example
02:32).The neck vessels are patent.
A right-sided Port-A-Cath is partially imaged. Approximately 4 mm left upper
lobe pulmonary nodule (2:62). Otherwise, the imaged portion of the lung
apices are clear. Fracture of the right lamina of C5 (02:40), of uncertain
chronicity.
IMPRESSION:
1. Extensive left cervical lymphadenopathy - may be reactive in etiology or
secondary to patient's neoplasm. Continue clinical follow up is recommended.
2. Patent bilateral internal jugular veins.
3. 1 cm hypodense right thyroid nodule.
4. Fracture of the right lamina of C5, of uncertain chronicity.
5. Approximately 4 mm left upper lobe pulmonary nodule.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Rash
Diagnosed with Zoster with other complications, Chronic lymphocytic leuk of B-cell type not achieve remis
temperature: 99.8
heartrate: 57.0
resprate: 16.0
o2sat: 100.0
sbp: 116.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | #C3 dermatome Herpes zoster:
Mr. ___ developed herpes zoster due to his
immunocompromised state. There was no evidence of cranial nerve
or organ involvement. He tested positive for VZV by ___. He was
treated with IV acyclovir 800 mg q8. He will complete a total 14
days, which was switched to PO Valtrex on d/c.
#Superimposed Skin an Soft tissue infection, cellulitis
While hospitalized, Mr. ___ had low grade temperatures of
100.6-100.8. Infectious work-up revealed a cellulitis in the
posterior C3 dermatome. He was started on IV vancomycin which
was narrowed to PO doxycycline at the time of discharge 100mg
BID to complete a total 7 day course (ending on ___ for
presumed superinfection with either staph or strep.
Unfortunately at time of d/c no culture result positive, final
culture and MRSA swab pending at time of d/c.
#CLL - He was continued on his home Venetoclax and allopurinol.
Rituximab infusions on hold until infection is cleared. To be
determined after f/u with heme/onc. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with history UC s/p right colectomy 2 months
ago for high-grade dysplasia the setting of ulcerative colitis,
complains of a new
right-sided abdominal pain that began at 8 ___ this evening, and
has been constant since that time, intense dull pain, denies
history of similar. Denies fevers/chills, nausea/vomiting, chest
pain, dyspnea, diarrhea, bright red blood per rectum, melena,
constipation. Last bowel movement this afternoon. His physician
made ___ house call this evening, noted right upper quadrant
tenderness, and was concerned for cholecystitis, so referred him
to the ED. Pt reports passing flatus and being able to tolerate
PO. He had a large meal last night and denied any pain or nausea
afterwards. In the ED the patient became nausea and emesis prior
to NGT placement.
Past Medical History:
UC
Carotid stenosis
Dyslipidemia
DVT
Hypertension
MI
CABG
Crohn's
Arthritis
Right colectomy (___)
Social History:
___
Family History:
Mother died in ___ of ? GI cancer. Father died in ___ of cardiac
disease. No FH IBD or other GI illnesses.
Physical Exam:
98.4 67 116/52 18 99ra PO 540 Urine 610 IVF 800 BM x 4
Gen: AOx3, NAD
CV: RRR s1s2nl
Resp: CTAB, no w/r/r
Abd: soft, non-tender, non-distended, normal bowel sounds
extremities: no cce
Pertinent Results:
___ 11:40PM BLOOD WBC-12.4* RBC-4.17* Hgb-13.2* Hct-39.9*
MCV-96 MCH-31.5 MCHC-32.9 RDW-13.3 Plt ___
___ 11:40PM BLOOD Neuts-70.1* ___ Monos-4.4 Eos-0.4
Baso-0.2
___ 09:35AM BLOOD ___ PTT-29.3 ___
___ 11:40PM BLOOD Glucose-109* UreaN-34* Creat-1.1 Na-142
K-4.8 Cl-103 HCO3-29 AnGap-15
___ 11:40PM BLOOD ALT-11 AST-20 AlkPhos-56 TotBili-0.2
___ 11:40PM BLOOD Albumin-4.6
CT abd/pel ___: The small bowel appears diffusely dilated
and mostly fluid filled consistent with small bowel obstruction.
Note is made of fecalization of the terminal ileum. The
transition point appears to be within the mid abdomen where
there is a segment of bowel that shows thickened wall (2, 57).
There is free fluid. Vague adjacent mesenteric fluid is noted
which may suggest congestive changes associated with obstruction
or potentially even ischemia. Other considerations are
inflammatory bowel disease, less likely infectious etiology.
RUQ US ___: Moderately distended gallbladder with
cholelithiasis and sludge, but without specific signs for
cholecystitis. Trace ascites and pericholecystic fluid.
Medications on Admission:
acetaminophen 1000''' PRN, verapamil 120'', simvastatin 10',
digoxin 62', levothyroxine 25', oxycodone 5' Q4H PRN, tamsulosin
0.4', warfarin 4' W/Th/Fr, 2'other days, ursodiol 300''',
sulfasalazine 1000''
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. verapamil 120 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO W, TH, FR ().
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO ___, SA, ___ ().
9. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
11. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (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
INDICATION: ___ man with abdominal pain, evaluate for cholecystitis.
COMPARISON: Abdominal US, ___.
LIVER AND GALLBLADDER US: The liver is normal in echogenicity with no focal
lesions present. The gallbladder is moderately distended with small stones and
sludge within it. No gallbladder wall thickening is present. No sonographic
___ sign was elicited. The common bile duct measures 3 mm. The portal
vein is patent. The partially imaged pancreas appears unremarkable. There is
trace amount of ascites and pericholecystic fluid.
IMPRESSION:
1. Moderately distended gallbladder with cholelithiasis and sludge, but
without specific signs for cholecystitis.
2. Trace ascites and pericholecystic fluid.
Radiology Report
INDICATION: ___ man with right-sided abdominal pain and right mid to
lower tenderness with acute onset six hours ago. Patient is status post right
colectomy two months ago.
COMPARISON: CT abdomen and pelvis with contrast ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis
with the administration of IV contrast. Multiplanar reformats were generated
and reviewed.
CT OF THE ABDOMEN: The visualized lung bases show bibasilar dependent
atelectasis but no focal consolidation or pleural effusion. The visualized
heart and pericardium are unremarkable.
The liver appears unremarkable. The gallbladder is distended and contains
gallstones and sludge; however, there is no gallbladder wall hyperemia or
thickening consistent with cholecystitis. The pancreas is atrophic and
otherwise unremarkable. The spleen appears surgically absent. Both kidneys
enhance and excrete contrast symmetrically without evidence of hydronephrosis
or renal calculi. Subcentimeter hypodensities in both kidneys are too small
to characterize but likely represent renal cysts. Bilateral adrenal glands
are unremarkable.
The abdominal aorta shows extensive atherosclerotic calcification extending
into the common iliacs. There is extensive atherosclerotic calcification
extending into the hepatic arteries. There is no free air within the abdomen.
There is atherosclerotic calcification of the SMA origin. The celiac artery
appears stenotic. Patency of the ___ cannot be assessed.
The patient is status post right colectomy. The transverse and descending
colon appeared distended and filled with air and feces.
The small bowel appears diffusely dilated and mostly fluid filled consistent
with small bowel obstruction. Note is made of fecalization of the terminal
ileum. The transition point appears to be within the mid abdomen where there
is a segment of bowel that shows thickened wall (2, 57). There is free fluid.
Vague adjacent mesenteric fluid is noted which may suggest congestive changes
associated with obstruction or potentially even ischemia. Other considerations
are inflammatory bowel disease, less likely infectious etiology. The stomach
is distended.
CT OF THE PELVIS: The bladder, distal ureters, rectum and sigmoid colon are
unremarkable. Prostate appears mildly enlarged. There are bilateral
fat-containing inguinal hernias. Surgical clips are noted within the right
groin.
Visualized osseous structures show no focal lytic or sclerotic lesion
suspicious for malignancy.
IMPRESSION:
1. The small bowel appears diffusely dilated and mostly fluid filled
consistent with small bowel obstruction. Note is made of fecalization of the
terminal ileum. The transition point appears to be within the mid abdomen
where there is a segment of bowel that shows thickened wall (2, 57). There is
free fluid. Vague adjacent mesenteric fluid is noted which may suggest
congestive changes associated with obstruction or potentially even ischemia.
Other considerations are inflammatory bowel disease, less likely infectious
etiology.
2. Cholelithiasis and gallbladder sludge.
Updated findings were discussed with Dr. ___ at 7:10am on ___ via
telephone.
Radiology Report
INDICATION: ___ man with NG tube placement. Confirm NG tube
placement.
COMPARISON: PA and lateral chest radiograph ___.
PORTABLE AP CHEST RADIOGRAPH:
The nasogastric tube appears to pass into the right main stem bronchus and
should be removed and repositioned. Bilateral low lung volumes are noted with
crowding of bronchovascular markings. Bibasilar opacification is consistent
with atelectasis. Cardiac silhouette is top normal.
Note is made of gastric distention in the left upper quadrant.
Findings were discussed with Dr. ___ at 7:45 a.m. on ___ via
telephone.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 97.9
heartrate: 95.0
resprate: 14.0
o2sat: 100.0
sbp: 129.0
dbp: 53.0
level of pain: 8
level of acuity: 3.0 | Patient was admitted for presumed small bowel obstruction. His
CT scan from the ED did call a transition point however the
patient continued to pass flatus and had a bowel movement as
recently as the evening before. He also had stool throughout the
colon and in parts of the small bowel and PO contrast had made
it past the tranisition point. A RUQ ultrasound was also done as
he had initial RUQ pain, but this showed no evidence of
cholecystitis and neither did his LFTs. The NGT that was placed
in the ED for nasuea and emesis was removed before his arrival
to the floor. On getting to the floor he had a soft abdomen that
was non-distended and non-tender. He had no nausea and felt well
enough that the NGT was not replaced. He was given a tap water
enema, which led to a large bowel movement and symptomatic
relief. He was then started on milk of magnesia and had a second
BM that same day. He had his diet advanced from clears to
regular on ___, which he tolerated well. He also had all of
his home medications restarted, including coumadin after
admission INR was 2.0. Upon discharge he was tolerating a
regular diet, having regular bowel movements and passing flatus.
He was ambulating without difficulty. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ w/ ___ w/ mild dementia, CAD s/p
six-vessel CABG, CHF, severe aortic Stenosis, mild pulm HTN,
HTN,
DL, T2DM, SSS s/p ___ and Afib who p/w fall. He fell down 3 steps
of stairs at home w/o LOC. He thinks he slipped on a bathrobe.
His friend/caretaker found him after he called from his phone
and
had him brought to the hospital by EMS.
On arrival, pt was found to have anemia, thrombocytopenia, w/ an
elevated WBC w/ 55% atypical cells. Was evaluated by oncology
fellow for c/f acute leukemia and pt was transferred to ___.
On further evaluation, he had seen his primary care doctor on
___ and was found to have a leukocytosis at that visit. He was
promptly referred to Dr. ___ but
could not provide further details about that visit. His wife was
able to clarify that they had met Dr. ___ were told that he
likely had lymphoma/leukemia, but she could not remember the
details. Dr. ___ was closed on the day of admission.
REVIEW OF SYSTEMS:
Pt denies chest pain, abdominal pain, heart palpitations,
nausea,
vomiting, diarrhea, or new rashes. His wife notes lack of
appetite at home and that he has been sleeping a lot for the
last
few months.
Past Medical History:
1. CKD stage II-III secondary to diabetic nephropathy with sub
nephrotic proteinuria; baseline creatinine around 1.5.
2. Congestive heart failure.
3. History of coronary artery disease.
4. Status post CABG in ___.
5. Hypertension.
6. Hyperlipidemia.
7. Diabetes mellitus.
8. ___ disease.
9. Aortic stenosis, aortic valve area is 1.3 cubic cm.
10. Mild pulmonary hypertension.
11. Sick sinus syndrome, status post pacemaker placement.
12. Status post TURP done ___ years ago.
13. Mild dementia.
14. Atrial fibrillation (no longet anticoagulated)
15. Status post left arthroscopic knee surgery.
Social History:
___
Family History:
Positive for CHF, CKD, hypertension, CAD, prostate cancer and
CVA
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: 98.0 60 166/70 16 98% RA
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RRR, ___ SEM radiates to axilla
NECK: JVP 12 cm
PULM: fine crackles in ___ bases
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___, no resting tremor
SKIN: scattered petechiae over ___ arms
NEURO: Altert and oriented to self and time, moves all four
extremities spontaneously.
DISCHARGE EXAM:
VITALS: 97.6PO 105 / 54 61 18 98 RA
GENERAL: Elderly gentleman, laying in bed in NAD
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
NECK: JVP at angle of mandible
CV: RRR, ___ SEM radiates to axilla
PULM: scattered crackles in bilateral bases and coarse rhonchi
scattered throughout
ABD: BS+, soft, NT/ND, no palpable masses or HSM
LIMBS: WWP, no ___, no resting tremor
SKIN: scattered petechiae over ___ arms
NEURO: Alert and oriented to self and time, moves all four
extremities spontaneously.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:27PM BLOOD WBC-20.9*# RBC-3.38* Hgb-10.5* Hct-31.9*
MCV-94 MCH-31.1 MCHC-32.9 RDW-15.0 RDWSD-51.5* Plt Ct-91*
___ 06:27PM BLOOD Neuts-7* Bands-0 Lymphs-91* Monos-1*
Eos-1 Baso-0 ___ Myelos-0 Other-0 AbsNeut-1.46*
AbsLymp-19.02* AbsMono-0.21 AbsEos-0.21 AbsBaso-0.00*
___ 06:27PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:27PM BLOOD ___ PTT-29.6 ___
___ 02:42AM BLOOD ___ 06:27PM BLOOD Ret Aut-2.4* Abs Ret-0.08
___ 06:27PM BLOOD Glucose-109* UreaN-34* Creat-1.5* Na-144
K-4.2 Cl-104 HCO3-28 AnGap-12
___ 06:27PM BLOOD ALT-<5 AST-11 LD(LDH)-332* AlkPhos-47
TotBili-0.6
___ 06:27PM BLOOD Albumin-4.0 UricAcd-8.8*
___ 06:27PM BLOOD VitB12-413 Hapto-11*
___ 01:15PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:27PM BLOOD LtGrnHD-HOLD
___ 01:15PM BLOOD HCV Ab-NEG
___ 06:40PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 05:58AM BLOOD WBC-23.7* RBC-3.19* Hgb-9.8* Hct-29.8*
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.8 RDWSD-50.4* Plt Ct-99*
___ 05:58AM BLOOD Plt Ct-99*
___ 05:58AM BLOOD Glucose-103* UreaN-48* Creat-1.8* Na-141
K-3.8 Cl-98 HCO3-29 AnGap-14
___ 06:07AM BLOOD ALT-<5 AST-9 LD(LDH)-270* AlkPhos-47
TotBili-0.6
___ 05:58AM BLOOD Calcium-8.9 Mg-2.2
PERTINENT RESULTS:
==================
CYTOGENETICS: pending on discharge
IMMUNOPHENOTYPING: pending on discharge
IMAGING:
=======
NCHCT ___
IMPRESSION:
No acute intracranial process.
CT C-SPINE ___
IMPRESSION:
1. No acute fracture or dislocation of the cervical spine.
Multilevel
degenerative changes, as above, with areas of central canal
narrowing.
2. Partially imaged right lung apex shows suggestion of mild
septal
thickening, which could relate to component of pulmonary edema.
CXR ___
IMPRESSION:
Relatively low lung volumes with some pulmonary vascular
congestion. Possible trace pleural effusion. Mild
cardiomegaly.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Bumetanide 1 mg PO BID
3. Sertraline 50 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. galantamine 8 mg oral BID
6. Carvedilol 12.5 mg PO BID
7. HydrALAZINE 10 mg PO TID
8. Vitamin D ___ UNIT PO DAILY
9. Carbidopa-Levodopa (___) 0.5 TAB PO TID
Discharge Medications:
1. Carvedilol 25 mg PO BID
2. HydrALAZINE 25 mg PO Q8H
3. Bumetanide 1 mg PO BID
4. Carbidopa-Levodopa (___) 0.5 TAB PO TID
5. galantamine 8 mg oral BID
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Sertraline 50 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Elevated white blood cell count, likely chronic leukemia
Mechanical fall
Hypertension
Orthostatic hypotension
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall// pna? fracture?
TECHNIQUE: Single AP supine portable view of the chest
COMPARISON: ___
FINDINGS:
Dual lead left-sided pacer device is seen, with leads extending to the
expected positions of the right atrium and right ventricle. Cardiac
silhouette remains mildly enlarged. The aorta is calcified. Indistinctness
and fullness of the hila bilaterally suggests pulmonary vascular congestion.
There may be trace pleural effusions. No definite focal consolidation is
seen. There is no evidence of pneumothorax. Patient is status post median
sternotomy. No displaced rib fracture identified.
IMPRESSION:
Relatively low lung volumes with some pulmonary vascular congestion. Possible
trace pleural effusion. Mild cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall// bleed? fracture?
TECHNIQUE: Noncontrast enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
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: ___ thirteen
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. Prominence of the
ventricles and sulci is consistent with involutional changes. Periventricular
and subcortical white matter hypodensities are likely sequelae of chronic
small vessel disease. The visualized paranasal sinuses the partially imaged
mucous retention cyst in the right maxillary sinus. The mastoid air cells are
clear. No acute fracture is seen.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall// bleed? fracture? bleed? 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 = 22.7 mGy (Body) DLP = 505.7
mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: ___
FINDINGS:
Alignment is normal.No acute fracture seen. Multilevel degenerative changes
are re-demonstrated including prominent ossification of the anterior
longitudinal ligament, most noted at C3/C4, C5/C6. Slight apparent widening
of the C4/C5 disc space is stable.There is mild to moderate central canal
narrowing at C3/C4 due to posterior disc osteophyte. Mild central canal
narrowing is seen at C4/C5, C5/C6, and C6/C7. 8 mm rounded sclerotic focus in
the C7 vertebral body is similar to prior. There is no prevertebral soft
tissue swelling. Arterial calcifications are seen. The very partially imaged
lung apices demonstrate suggestion of mild septal thickening at the right lung
apex, which could relate to a component of pulmonary edema.
IMPRESSION:
1. No acute fracture or dislocation of the cervical spine. Multilevel
degenerative changes, as above, with areas of central canal narrowing.
2. Partially imaged right lung apex shows suggestion of mild septal
thickening, which could relate to component of pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Weakness
temperature: 98.4
heartrate: 84.0
resprate: 16.0
o2sat: 98.0
sbp: 180.0
dbp: 108.0
level of pain: 0
level of acuity: 2.0 | ___ w/ ___ w/ mild dementia, CAD s/p CABG, CHF, Severe
Aortic Stenosis, mild pulm HTN, HTN, DL, SSS s/p ___ and Afib who
p/w fall, found to have labs c/f acute leukemia. Pt was admitted
and after further work-up, was suspected to have CLL.
# CLL: WBC noted to be elevated to the low to mid-20's on
admission. Initially c/f acute leukemia but on further review,
has been found as an OP and was followed by Dr. ___. Pt
initially admitted to ___ unit but plan is to continue to
monitor for now. Dr. ___ not be reached. Pt will follow
with Dr. ___ as an outpatient per family request. Cytogenetics
pending on discharge.
# Fall: suspect mechanical given pt's recollection of tripping
on a bathrobe. No reports of syncopal event. Pt had negative
trauma work up in the emergency department and will be
discharged to rehab for further ___.
# CHF: continued home bumex and carvedilol. Pt with crackles on
exam and elevated JVP. However, he denied symptoms of dyspnea
and was sat'ing well on RA. Attempted to diurese with 1x
additional 40mg IV Lasix but pt became more orthostatic with Cr
that became more elevated so plan was to hold further diuresis
as he otherwise appeared stable. Discharged on home 1mg BID
bumex.
# HTN/Orthostatic hypotension: continued home hydralazine and
carvedilol as above. Pt was found to be hypertensive on home
regimen and hydralazine was uptitrated from 10mg TID to 25mg
TID. Carvedilol was also increased from 12.5BID to 25BID. Pt
still quite hypertensive at times to 170's-180's systolic
despite this regimen but was also profoundly orthostatic (though
asymptomatic) and with very labile BP's so no further
medications were added.
# CAD s/p CABG: continue home nitroglycerin
# ___ Disease: Continue home sinemet
TRANSITIONAL ISSUES
===================
[] Pt will need follow up with Dr. ___ in ___
[] Pt was found to have 2cm L thoracic skin growth that should
be evaluated by primary care doctor
[] Please f/u BP's and titrate carvedilol/hydralazine prn
Billing: Greater than 30 minutes spent on discharge counseling
and coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Morphine
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with HIV-related stage 4
diffuse large B-cell lymphoma s/p 9 cycles of dose-attenuated
EPOCH and intrathecal high-dose methotrexate for CNS
prophylaxis, HIV (on triple HAART with near complete
suppression), CAD, DL, T2DM, depression, recently admitted to
___ for N/V, and concern for leptomeningeal spread. The patient
was having confusion and some ataxia. He underwent multiple LPs
which did not show infection or malignant cells. The presumptive
diagnosis was aseptic chemical arachnoiditis and neurotoxicity
secondary to liposomal cytarabine. During that hospitalization,
the patient had a fall with left hip fracture requiring ORIF. He
was sent to rehab on ___. He followed up in ___
clinic on ___. He seems to be in clinical remission from his
DLBCL and does not seem to have active CNS disease at this time.
The patient comes back in from rehab due to a fall. Patient
states he had to use the restroom and got out of the wheelchair
and lost his balance and fell forwards hitting his head. Patient
denies LOC, neck pain or other trauma. He denies any change in
urination although he does say that he has had trouble voiding
and emptying his bladder for quite some time.
In the ED, initial vitals were: 96.8 76 132/62 20 100% RA.
While in the ED, temp rose to 101.2 and HR was as high as 110.
CT abd/pelvis showed a markedly distended bladder and
hydroureteronephrosis concerning for obstruction, no e/o
hematoma or abcess, stable enlarged inguinal LN. Head CT showed
no hemorrhage, evidence of acute large vascular territory
infarction, or sequelae of trauma. UA was notable for many
bacteria, >182 WBCs, positive nitrates and leuks. Labs were
notable for AG of 23. He was given Zofran, Tylenol, ceftriaxone
and 2 L NS.
On the floor, the patient is a poor historian. He has no
complaints.
Past Medical History:
PAST ONCOLOGIC HISTORY(per OMR):
Patient was diagnosed in ___ with diffuse large B cell
lymphoma, stage 4, after presenting with anterior chest wall
fullness. U/S exam on ___ revealed a 9.6 x 5.4 x 8.4 cm
heterogeneous mass in the R chest wall; CT imaging showed
association w/ R serratus anterior muscle and ipsilateral
axillary adenopathy and 3 small R pulmonary nodules (1-3cm
each).
On ___ patient underwent U/S guided needle biopsy, which
was consistent with high-grade non-Hodgkin's lymphoma. KI-___
immunostaining approx 80-90% pos for CD20, CD10, BCL6, and
focally BCL2. MUM1 negative. CD3 and CD5 highlighted
interspersed T cells. CT5 was focally and dimly positive in some
aplastic cells. FISH analysis was pos for MIC rearrangement, neg
for IGH-BCL2 fusion, and BCL6 rearrangement, pos for gain of
BCL6 and IGH. No Myc and BCL-6 translocation were noted. Hence
diagnosis was confirmed to be high grade large B-cell
lymphoma-GC origin but not double hit.
___: PET demonstrated a 10.1 x 4.3 cm irregular mass within
the right anterior chest wall demonstrating significant FDG
avidity. Multiple sites of FDG avid lymphadenopathy identified
within the bilateral axilla, mediastinum, porta hepatis, and
left pelvic sidewall. 3. Multiple sites of distant metastatic
disease within the liver and right adrenal gland. Additional
sites of osseous metastases are seen at the levels of T11, L1,
and L4. Focus of increased FDG uptake within the right prostate
was concerning for primary malignancy.
___: BM biopsy did not demonstrate any e.o lymphoma or
prostate CA.
___: Case discussed with Dr ___ email and scans
reviewed by him at ___ tumor board and it was felt that the
prostate avidity was non-specific and not concerning. In the
light of a normal PSA level and absence of cancer on BM biopsy,
it would be unlikely for him to have disseminated prostate CA in
addition to known diagnosis of high grade lymphoma which could
explain the PET findings.
___: HIV AB REPORTED POSITIVE. Confirmed by repeat test and
case discussed with ID.
___: HIV-1 Viral Load: 115,000 copies/ml. HepB core Ab was
also found to be positive with neg HBV viral load and HCV viral
load. CD4 count 280
Prognosis according to the R-IPI (Revised International
Prognostic Index) is 'poor' with predicted ___
progression-free survival of 53% and overall survival of 55%.
Additional Risk factor: HIV untreated, HepB core Ab positive,
viral load negative
___: Admitted inpatient for cycle 1 level 1 of
DA-EPOCH. Tolerated chemotherapy well without any complications.
Also started on HAART with Truvada and Dolutegravir as inpatient
for HIV infection and prophylaxis for hepB reactivation while he
gets Rituximab. His bulky anterior rt chest wall tumor shrunk at
the end of completion of the cycle. ANC nadir <200 without
Neupogen.
___: Rcd Rituximab and 1st dose of IT MTX for primary CNS
prophylaxis. CSF cytology was negative for lymphoma.
___: Rcd IV fluids, zofran in clinic and was
started on zyprexa at home for headaches, nausea. Tolerated it
well and did not need inpatient hospitalization.
___: Received 2nd dose of IT MTX. CSF showed atypical
lymphocytes as before but cytology was negative.
___: Rcd cycle 2 of DA-EPOCH as inpatient (rcd
level 1 again as nadir ANC was <200 off Neupogen). Tolerated it
well without any complications.
___: Rcd Rituxan as part of cycle 2 of DA-EPOCH. Tolerated
well.
___: Nadir ANC during cycle 2 was 80 on Neupogen. Tolerated
cycle 2 well without any fevers, nausea, vomiting etc.
___: PET after cycle 2 demonstrated CR.
___: Received cycle 3 of DA-EPOCH as inpatient
(rcd level 1 again as nadir ANC was 80 on Neupogen). Tolerated
it well without any complications. Rcd 3rd dose of IT MTX. CSF
showed only 4 WBC's. Too few cells present to perform flow.
___: Rcd Rituxan administration as part of cycle 3 of
chemotherapy.
___: Nadir ANC 294.
___: Received cycle 4 of DA-EPOCH as inpatient
(rcd level 1 again as nadir ANC was 294 on Neupogen). Tolerated
it well without any complications. Rcd 4th dose of IT MTX. CSF
unremarkable again for lymphoma involvement.
___: ANC nadir 115. Had a mechanical fall, followed by and
c.o low back pain when rising from chair. On evaluated found to
have a Compression fracture of the L2 vertebral body with 25%
loss of height.
___: Seen in clinic for follow up and found to be doing
well with minimal pain on Lidoderm patch.
___: PET after cycle 4 demonstrated CR.
___: Rcd IT Ara-C (dose 5 of IT chemo but 1st dose
of Ara-C and was then admitted for cycle 5 of DA-EPOCH (level
1). Rcd Rituxan on ___. Tolerated it well without any
complications.
___: Received IT Ara-C (dose 6 of IT chemo but ___
dose of Ara-C)and was then admitted for cycle 6 of DA-EPOCH
(level 1). Received Rituxan on ___. Tolerated it well
without any complications.
___: PET fater cycle 6 demonstrated CR.
___: Echo after completion of therapy demonstrated normal
EF.
___: Evaluated by Rad-onc and completed a 30.6 Gy
course of consolidative IFRT to the rt bulky chest wall mass
without any complications.
Treatment History:
___: cycle 1 level 1 of DA-EPOCH. Also started on
HAART with Truvada and Dolutegravir as inpatient for HIV
infection and prophylaxis for hepB reactivation while he gets
Rituximab.
___: Received Rituximab and 1st dose of IT MTX for primary
CNS prophylaxis. CSF cytology was negative for lymphoma.
___: Cycle 2 DA-EPOCH Level 1 and IT MTX. ___:
Rituxan
___: PET after cycle 2 demonstrated CR.
___: Cycle 3 of DA-EPOCH Level 1 and IT MTX.
___: Rituxan
___: Cycle 4 of DA-EPOCH Level 1, and IT MTX.
___: PET after cycle 4 demonstrated CR.
___: IT Ara-C (dose 5 of IT chemo but 1st dose of
Ara-C) and cycle 5 of DA-EPOCH (level 1). Rituxan on ___.
___: Rcd IT Ara-C (dose 6 of IT chemo but 2nd dose
of Ara-C) and cycle 6 of DA-EPOCH (level 1). Rituxan ___.
(1) episodic focal motor seizure in late ___,
(2) a gadolinium-enhanced head MRI on ___ showed
enhancement
in the right frontal brain,
(3) a lumbar puncture on ___ WBC, 119 protein, 5 glucose, 78
LDH, and aytpical cells on cytology and flow cytometry, and
(4) started liposomal cytarabine on ___ and had 1 dose so
far, and
(5) started high-dose methotrexate on ___ and rituximab on
___.
(6) started C1 liposomal cytarabine on ___,
(7) received C2 high-dose methtorexxate on ___,
(8) received C2 liposomal cytarabine and rituximab on ___,
(9) received C3 liposomal cytarabine and rituximab on ___,
(10) received C3 high-dose methtorexxate on ___,
(11) received C4 liposomal cytarabine and rituximab on ___,
(12) received C4 high-dose methtorexxate on ___,
(13) received C5 liposomal cytarabine and rituximab on ___,
(14) received C5 high-dose methtorexxate on ___,
(15) received C6 liposomal cytarabine and rituximab on ___,
(16) received C6 high-dose methtorexxate on ___,
(17) MRI of thoracic and lumbar spine on ___ showed no
disease
(18) MRI of cervical spine and brain on ___ showed no
disease
(19) lumbar puncture on ___ showed CSF with 0 WBC, 7 RBC,
64 protein, 129 glucose, 18 LDH and cytology with atypical
cells,
(20) received C7 liposomal cytarabine and rituximab on ___,
(21) received C7 high-dose methtorexate on ___.
(22) received C8 liposomal cytarabine and rituximab ___
(23) C8 Rituxan/IT Cytarabine ___
(24) C9 Rituxan/IT Cytarabine ___
PAST MEDICAL HISTORY (per OMR):
- High Grade Diffuse Large B Cell Lymphoma, Stage 4
- Squamous Cell Skin Carcinoma
- DM2:A1Cs on review range from ___. He has not experienced any
peripheral neuropathy, retinopathy, proteinuria.
- CAD s/p PTCA in ___ and ___. Last stress test ___.
- Hyperlipidemia
- Anemia
- Depression
- Psoriasis
- GERD
- HIV+: Diagnosed concurrent with DLBCL. CD4 at presentation
280; HIV VL 103,000 copies/mL. He is RPR nonreactive, CMV IGG
positive and Toxoplasma IGG negative. He was started on
tenofovir/emtricitabine/raltegravir with a rapid but incomplete
HIV suppression. The raltegravir was changed to dolutegravir to
simplify dosing with his frequent hospitalizations, and
maraviroc was added in ___ due to persistent low level
HIV viremia (~80-120 copies/mL). Most recent HIV VL was
___ at 120 copies/mL and CD4 count was 293.
- HBcAb positive; HBsAg and HBV VL negative
- Admitted ___ for fracture left hip, treated with
left TFN by ___
- Admitted ___ for dizziness: Concerning for
relapse/disease progression. MRI brain and spine is did not show
parenchymal or leptomeningeal enhancement. LP performed w/
elevated WBC, no clinical evidence of infectious meningitis,
cytology w/ atypical lymphoid cells, inadequate for flow.
Social History:
___
Family History:
Mother deceased at ___ from APL. Father is alive at ___ with
coronary artery disease. He has no full siblings. He is of
___ and ___ descent.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5, 128/82, 90, 22, 94% on RA
GENERAL: NAD, ill-appearing obese female lying flat in bed in
nad
HEENT: mmDry, poor dentition, no lesions of mouth
CARDIAC: RRR, nml S1 and S2, no m/r/g
CHEST: Port in place over R chest wall
LUNG: CTAB on anterior exam, no labored respirations
ABD: soft, obese, NTND, decreased bowel sounds
EXT: significant lymphedema of BLE
NEURO: AOx3, appropriately interactive, able to spontaneously
move all extremities
SKIN: wwp, some increased erythema over RLE (improved from
prior per patient)
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS
--------------
___ 07:30PM BLOOD WBC-7.7# RBC-3.38* Hgb-10.3* Hct-31.8*#
MCV-94 MCH-30.5 MCHC-32.4 RDW-15.4 RDWSD-53.6* Plt ___
___ 07:30PM BLOOD Neuts-45.3 ___ Monos-6.1 Eos-3.3
Baso-0.5 Im ___ AbsNeut-3.47 AbsLymp-3.33 AbsMono-0.47
AbsEos-0.25 AbsBaso-0.04
___ 07:30PM BLOOD ___ PTT-37.4* ___
___ 07:30PM BLOOD Glucose-186* UreaN-12 Creat-0.9 Na-136
K-4.8 Cl-95* HCO3-18* AnGap-28*
___ 07:30PM BLOOD ALT-10 AST-32 AlkPhos-205* TotBili-0.6
___ 05:18AM BLOOD Calcium-7.9* Phos-2.3* Mg-1.7
___ 07:30PM BLOOD Albumin-3.6
___ 08:50PM BLOOD Lactate-2.4*
___ 10:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:00PM URINE Blood-TR Nitrite-POS Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:00PM URINE RBC-2 WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
DISCHARGE LABS
--------------
___ 06:30AM BLOOD WBC-2.6* RBC-2.51* Hgb-7.8* Hct-23.3*
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.9 RDWSD-50.4* Plt ___
___ 06:30AM BLOOD Glucose-161* UreaN-6 Creat-0.5 Na-138
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 06:30AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.9
MICROBIOLOGY
------------
___ BLOOD CULTURES: NO GROWTH AT DISCHARGE
___ URINE CULTURE:
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
-------
___ CT HEAD:
IMPRESSION:
No hemorrhage, evidence of acute large vascular territory
infarction, or
sequelae of trauma. Stable mild prominence of the ventricles.
___ CT ABDOMEN/PELVIS:
IMPRESSION:
1. Markedly distended bladder. Secondary upstream moderate
hydroureteronephrosis with delayed excretion of contrast
suggesting
obstruction. Foley decompression should be considered. The
prostate is
heterogeneous and partially calcified, though not markedly
enlarged.
2. No evidence of intra-abdominal hematoma or abscess.
3. Stable, enlarged left inguinal lymph node.
___ CXR PA+LAT:
IMPRESSION:
No acute cardiopulmonary process.
___ EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
disorganized and slow background throughout with some bursts of
generalized slowing or suppression. These findings indicate a
moderately severe encephalopathy. Medications, metabolic
disturbances, and infection among the most common causes. There
were no areas of prominent focal slowing, but encephalopathies
may obscure focal findings. There were no epileptiform features
or electrographic seizures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY:PRN constip
3. Enoxaparin Sodium 40 mg SC Q24H
4. Acyclovir 400 mg PO Q8H
5. Atorvastatin 10 mg PO QPM
6. Atovaquone Suspension 1500 mg PO QHS
7. BusPIRone 5 mg PO TID
8. Calcium Carbonate 500 mg PO BID:PRN heartburn
9. Cyanocobalamin 250 mcg PO DAILY
10. Dolutegravir 50 mg PO DAILY
11. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
13. HydrOXYzine 25 mg PO Q6H:PRN itching
14. Maraviroc 300 mg PO BID
15. Senna 17.2 mg PO BID constip
16. Simethicone 120 mg PO QID:PRN GERD/indigestion
17. TraZODone 25 mg PO QHS:PRN insomnia
18. Acetaminophen 1000 mg PO TID
19. Aspirin 81 mg PO DAILY
20. MetFORMIN (Glucophage) 500 mg PO TID
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. Tamsulosin 0.4 mg PO QHS
23. Ranitidine 150 mg PO DAILY
24. Prochlorperazine 10 mg PO Q6H:PRN nausea
25. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
26. Hydrocerin 1 Appl TP BID apply to dry skin on extremities
27. Vitamin D 400 UNIT PO DAILY
28. Docusate Sodium 100 mg PO BID
29. Mirtazapine 7.5 mg PO QHS
30. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
31. Ondansetron 4 mg IV Q8H:PRN nausea
32. Nitrofurantoin Monohyd (MacroBID) 50 mg PO QID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Atovaquone Suspension 1500 mg PO QHS
6. BusPIRone 5 mg PO TID
7. Calcium Carbonate 500 mg PO BID:PRN heartburn
8. Cyanocobalamin 250 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Dolutegravir 50 mg PO DAILY
11. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
12. Hydrocerin 1 Appl TP BID apply to dry skin on extremities
13. HydrOXYzine 25 mg PO Q6H:PRN itching
14. Maraviroc 300 mg PO BID
15. Mirtazapine 7.5 mg PO QHS
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
18. Polyethylene Glycol 17 g PO DAILY:PRN constip
19. Ranitidine 150 mg PO DAILY
20. Senna 17.2 mg PO BID constip
21. Tamsulosin 0.4 mg PO QHS
22. TraZODone 25 mg PO QHS:PRN insomnia
23. Vitamin D 400 UNIT PO DAILY
24. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
last day ___. Citalopram 10 mg PO DAILY
HELD On admission- Discuss with Rehab about continuing to take
26. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
27. MetFORMIN (Glucophage) 500 mg PO TID
28. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
29. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
30. Prochlorperazine 10 mg PO Q6H:PRN nausea
31. Simethicone 120 mg PO QID:PRN GERD/indigestion
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Sepsis due to urinary tract infection
Complicated cystitis due to citrobacter freundii
Urinary retention
Secondary:
Diffuse Large B Cell Lymphoma
HIV infection
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man with a history of meningeal lymphoma on Lovenox
presenting with fall and head strike evaluate for 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: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Unenhanced head CT ___. Brain MR from ___
FINDINGS:
There is no hemorrhage or evidence of acute large vascular territorial
infarction. A right frontal approach ventriculostomy catheter is in unchanged
position terminating near the foramen of ___. Pericatheter hypodensity is
similar compared to ___. There is no evidence pericatheter
hemorrhage. There is stable prominence of the ventricles. Prominence of the
sulci is consistent with age-appropriate global atrophy. The basal cisterns
are patent. There is no shift of normally midline structures. There is no
evidence of fracture. The globes and bony orbits are intact and unremarkable.
The visualized paranasal sinuses and mastoid air cells are clear. Carotid
siphon calcifications are noted.
IMPRESSION:
No hemorrhage, evidence of acute large vascular territory infarction, or
sequelae of trauma.
Stable mild prominence of the ventricles.
Radiology Report
INDICATION: ___ with abd pain s/p fall // evidence of infection or bleed
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Right chest wall port is seen in stable position. The lungs are clear without
focal consolidation or effusion. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abd pain s/p fallNO_PO contrast // evidence of
infection or bleed
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) = 710 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is mild intrahepatic biliary
ductal prominence as well as common bile duct prominence, likely related to
prior cholecystectomy. The gallbladder is surgically absent.
PANCREAS: The pancreas is somewhat diminutive. No focal pancreatic lesions
are seen. 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. No excretion of
contrast is identified suggesting a delayed nephrogram. There is bilateral
hydronephrosis without definite obstructive lesion seen on either side. The
bladder is markedly distended, likely resulting in symmetric
hydroureteronephrosis. There is no mild perinephric stranding.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder is markedly distended. There is no free fluid in
the pelvis.
REPRODUCTIVE ORGANS: The prostate appears heterogeneous, similar to recent
examination, with a configuration suggesting prior TURP.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. Again
noted is a prominent left inguinal lymph node, measuring up to 2.1 cm.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is vertebral body height loss of the L2 vertebral body, similar
to the recent examination. Fixation hardware seen in the left hip. No acute
fracture is identified.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Markedly distended bladder. Secondary upstream moderate
hydroureteronephrosis with delayed excretion of contrast suggesting
obstruction. Foley decompression should be considered. The prostate is
heterogeneous and partially calcified, though not markedly enlarged.
2. No evidence of intra-abdominal hematoma or abscess.
3. Stable, enlarged left inguinal lymph node.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Urinary tract infection, site not specified, Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 96.4
heartrate: 76.0
resprate: 20.0
o2sat: 100.0
sbp: 132.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ___ year old male with HIV-associated stage 4 DLBCL in clinical
remission without evidence of CNS involvement, HIV (on ART),
coronary artery disease, type 2 diabetes, and recent fall
requiring left trochanteric fixation nail who presented from
___ with a fall. On admission he was found to have
sepsis due to a urinary source. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Advair Diskus / Azathioprine /
Albuterol / Scallops / Fish Oil
Attending: ___.
Chief Complaint:
nausea, hypotension
Major Surgical or Invasive Procedure:
central line placement ___
History of Present Illness:
___ with PMH significant for CAD s/p PCI, RA, OA, chronic
diarrhea, GAVE, and recent hospitalization for recurrent UTI
that presents from her rehab facility with 1 day h/o worsening
lethargy and nausea. She reports waking up around 4AM this
morning with nausea. Denied fevers, chills, vomiting, abdominal
pain, dysuria, had mild hematuria. Patient has had pelvic XRT,
and as a result chronically self-caths with multiple UTIs in the
past due to Klebsiella and Enterobacter (Hafnia Alvei) resistant
only to macrobid, most recently admitted from ___ and
treated for humerus fracture and UTI. Had 2 negative urine cx's
and received 7 day course of cipro (finished on ___.
In the ED, initial vs were: 97.1 94 124/60 18 97% RA. Labs were
remarkable for a WBC of 15 with a left shift, sodium of 126 from
135, Cr 1.8 from 0.9, lactate 1.2 with repeat to 1.4. She
developed rigors, spiked a temperature to 102.1, and was
tachycardic to 140s-150s in the ED, hypotensive to SBPs ___,
Central line placed and levophed started. Desatted to 92% on RA
so was put on 2L NC. Received dose of tylenol ___ mg PO, toradol
for fever, ciprofloxacin 400 mg IV x1, zosyn 4.5 g IV x1, 3 L NS
boluses.
On arrival to the MICU, VS: 98.6 BP: 106/41 P: 112 R: 21 O2:
100% 3L NC. Patient was complaining of nausea.
Past Medical History:
Rheumatoid arthritis, currently on Embrel
CAD s/p PCI with 2 BMS in ___
Gastric Antral Vascular Ectasia, s/p thermal ablasion
Hypertension
hx of cervical cancer s/p XRT and radical hysterectomy ___
hx of chronic diarrhea after XRT (non-bloody)
s/p bilateral knee replacement due to osteoarthritis
s/p cholecystectomy
carpal tunnel syndrome
reactive airways disease.
Allergic Rhinitis.
Social History:
___
Family History:
Mother died of MI at age ___, father and brother both s/p CABG;
no DM; Brother had a self-limited pulmonary process a few months
ago.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.6 BP: 106/41 P: 112 R: 21 O2: 100% 3L NC
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley in place draining cloudy light brown urine
Ext- warm, well perfused, 2+ pulses, 1+ pitting edema, no
clubbing, cyanosis
Neuro- A+Ox3, mentating well, CNs2-12 intact, motor function
grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals- 98.2 86 148/57 18 99% RA
General- Alert, orientedx3, in no acute distress
HEENT- Sclera anicteric, oropharynx clear
Neck- supple, no LAD, no erythema/fluctuance/induration near
former IJ site
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate with occasional premature beats, normal S1, S2,
no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley
Ext- warm, well perfused, 2+ pulses, 1+ edema L>R. no clubbing,
cyanosis. PICC in place on R arm.
Neuro - intact to light touch ___ bilaterally. DG toes bilat.
improved strength in left hip flexion (4+/5).
Pertinent Results:
ADMISSION LABS:
___ 08:15PM BLOOD WBC-15.0* RBC-3.41* Hgb-9.5* Hct-28.1*
MCV-83 MCH-27.8 MCHC-33.7 RDW-15.6* Plt ___
___ 08:15PM BLOOD Neuts-94.9* Lymphs-2.4* Monos-2.4 Eos-0.2
Baso-0.1
___ 08:15PM BLOOD ___ PTT-33.1 ___
___ 08:15PM BLOOD Glucose-139* UreaN-24* Creat-1.8* Na-126*
K-4.3 Cl-91* HCO3-25 AnGap-14
___ 08:15PM BLOOD ALT-12 AST-19 AlkPhos-89 TotBili-0.4
___ 08:15PM BLOOD cTropnT-0.01
___ 02:00AM BLOOD CK-MB-3 cTropnT-0.04*
___ 08:15PM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.6 Mg-1.5*
___ 08:26PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 05:36AM BLOOD WBC-8.1 RBC-3.38* Hgb-9.4* Hct-27.9*
MCV-83 MCH-27.7 MCHC-33.5 RDW-15.3 Plt ___
___ 05:36AM BLOOD Plt ___
___ 02:18AM BLOOD ___ PTT-32.0 ___
___ 05:36AM BLOOD
___ 05:36AM BLOOD Glucose-78 UreaN-27* Creat-1.1 Na-138
K-4.9 Cl-103 HCO3-29 AnGap-11
___ 05:36AM BLOOD Calcium-6.8* Phos-2.1* Mg-1.5*
MICRO:
___ URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE (FINAL)
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
GRAM NEGATIVE ROD #2. ___ MORPHOLOGY.
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFTAZIDIME----------- =>___ R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURES (PENDING)
STUDIES:
___ Left shoulder Xray: 1) Healing fracture of left humeral
neck. 2) Possible pulmonary nodule.
___ Chest xray. No acute process. 11 mm LUL nodule seen on
___.
___ Chest xray. Right internal jugular line tip is at the
level of mid SVC. Heart size and mediastinum are stable. Lungs
are essentially clear. No pneumothorax or pleural effusion is
demonstrated.
___: chest X-ray: confirmed position of PICC in right SVC. Lung
nodule enlarged from prior study in ___, stable during
admission.
EKG:
___ NSR, normal axis, premature atrial contractions, TWI in
III, normal intervals.
___ NSR, premature atrial contractions, flattened T waves in
II, aVF, normal intervals
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Acetaminophen 650 mg PO Q4H:PRN fever, pain
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
5. Acetaminophen 1000 mg PO Q8H
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. PredniSONE 10 mg PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H
15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
16. Hydrochlorothiazide 12.5 mg PO DAILY
17. nystatin 100,000 unit/gram Topical BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
8. Pantoprazole 40 mg PO Q24H
9. PredniSONE 10 mg PO DAILY
10. Vancomycin Oral Liquid ___ mg PO Q6H
11. Meropenem 500 mg IV Q6H Duration: 12 Days
12. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
14. Acetaminophen 1000 mg PO Q8H
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Milk of Magnesia 30 mL PO DAILY:PRN constipation
17. Nystatin 100,000 unit/gram TOPICAL BID
18. Metoprolol Succinate XL 100 mg PO DAILY
19. Hydrochlorothiazide 12.5 mg PO DAILY
20. Lisinopril 5 mg PO DAILY
21. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Urinary tract infection
2) septic shock
3) Bacteremia
4) Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain and nausea.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: Left shoulder radiographs ___ and chest radiograph
___.
FINDINGS:
The cardiac silhouette size is mildly enlarged. The aorta is mildly tortuous.
Mediastinal and hilar contours are unchanged. Previous pattern of mild
pulmonary edema has improved. 11 mm nodular opacity projecting over the left
upper lung field remains unchanged. There is no focal consolidation, pleural
effusion or pneumothorax identified. Comminuted fracture of the proximal left
humerus seen is re- demonstrated.
IMPRESSION:
1. Resolution of the previously noted pulmonary edema. No acute
cardiopulmonary process.
2. 11 mm nodular opacity within the left upper lung field, for which a
nonemergent chest CT is recommended for further assessment, as was noted on
the prior shoulder radiographs.
3. Re- demonstration of comminuted fracture of the left proximal humerus.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with new right internal
jugular line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
Right internal jugular line tip is at the level of mid SVC. Heart size and
mediastinum are stable. Lungs are essentially clear. No pneumothorax or
pleural effusion is demonstrated.
Radiology Report
HISTORY: ___ female with right PICC placement.
COMPARISON: ___.
TECHNIQUE: Single frontal portable chest radiograph.
FINDINGS:
Right PICC tip is in low SVC. Since ___, there has been interval
increase in size of a rounded homogeneous opacity projecting over the
posterior left fifth rib that measures approximately 1 cm x 1 cm on today's
radiograph. No additional focal opacity. No pneumothorax. Heart size is top
normal with normal mediastinal contour and hila without lymphadenopathy.
Previously known left humeral head fracture is seen.
IMPRESSION:
1. Right PICC tip is in low SVC.
2. Since ___, increase in size of left upper lobe lung nodule.
Consider chest CT for further characterization.
On ___ results were entered into critical results by ___
___ to be conveyed to the referring physcian.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Nausea, Abd pain
Diagnosed with URIN TRACT INFECTION NOS, HYPOSMOLALITY/HYPONATREMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPERTENSION NOS
temperature: 97.1
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with a history of cervical cancer s/p xrt, now requiring
self-catheterization with recurrent UTIs presents for nausea and
lethargy concerning for urinary tract infection complicated by
septic shock.
ACUTE
# UTI c/b septic shock: Patient met criteria for shock with
fever, tachycardia, elevated WBC, hypotension requiring pressors
and (+)UA. She was started on vancomycin and cefepime for
empiric coverage of suspected UTI. On admission the patient had
a white blood cell elevation to 22, which downtrended during her
course. She was given 3L IV normal saline and was able to be
weaned off norepinephrine on the morning of ___. Lactates were
trended at 1.2 --> 1.4 --> 1.2. Urine culture grew Enterobacter
cloacae complex (R to ceftriaxone/ceftazidime/cipro/macrobid, S
to ___ and blood cultures grew the same.
She was started on meropenem on ___ to complete a ___fter 48 h of negative blood cultures (last dose planned ___. On the day of discharge, another organism was present in her
blood cultures but due to her clinical improvement with
meropenem and our inability to switch to another abx due to the
resistance patterns of the previously speciated organism, this
second organism would not change management. Her PICC was
confirmed to be in the proper position by chest X-ray prior to
discharge.
# ___: Cr 1.8 from baseline 0.9 most likely ___ pre-renal
azotemia in setting of urosepsis, hypotension, decreased PO
intake and chronic diarrhea. FeNa was 0.68% further indicative
of pre-renal azotemia. Patient was resuscitated with IV fluids
and creatinine downtrended to 1.2 at time of transfer to the
medicine floor.
# Hyponatremia: Na 126 from 135 on last admission most likely
___ hypovolemic hyponatremia in setting of decreased PO intake
and chronic diarrhea. Resolved with IVF administration.
# Demand ischemia: Most likely demand ischemia in setting of
tachycardia, sepsis. EKG with minimal < 1mm depressions in
lateral leads. Troponin peaked at 0.25 on hospital day 1. The
patient remained asymptomatic, heart rate normalized and EKG was
unchanged (normal). She was given her daily dose of ASA and the
norepinephrine was gradually weaned. Serial troponins were
measured and downtrended appropriately.
# Left humerus fracture: The patient sustained a left proximal
humerus fracture s/p fall in ___. This remained in
non-weight-bearing status with ROM limitations during her
course.
CHRONIC
# Chronic Diarrhea. The patient was diagnosed with C. Diff in
___ and has had recurrent episodes with courses of
antibiotics. Per OMR, completed oral vanco course for
prophylaxis during recent hospitalization. Clostridium difficile
was re-checked and negative. She was continued on her regimen of
PO vanc per discussion with her rehab facility.
# RA. On prednisone and Enbrel (last dose 4 weeks prior to
admission), but her enbrel was held due to her current
infection. Her 10 mg PO prednisone was briefly held in the ICU,
but restarted on the floor. Enbrel can be restarted as an
outpatient when she has improved.
# HTN. Her antihypertensives (lisinopril, HCTZ) were originally
held in the setting of septic shock, but were restarted at the
time of discharge due to improved kidney function and stable
vitals.
# HLD. Her atorvastatin was continued.
TRANSITION
# HTN. Her home meds (lisinopril and HCTZ) were held during this
admission, but restarted at the time of discharge. Recommend
following up her electrolytes and SBP in ___ weeks.
# Pulmonary nodule. 11mm LUL nodule seen incidentally on
shoulder film and confirmed on chest xray. Recommended follow up
with CT chest in ___ weeks once clinically stable. **Please
communicate this finding with PCP**
# UTI c/b bacteremia. She will need to complete a 14 day course
of IV meropenem by ___ in the outpatient setting (last dose
planned ___. PICC positioning was confirmed prior to
discharge. Her foley was left in at discharge to limit further
trauma due to self catheterization. This should be discontinued
prior to discharge from the rehab facility. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness, nausea, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo f, pmh of Steroid-responsive Encephalopathy Associated
with Autoimmune Thyroiditis on prednisone, presenting with
dizziness and nausea since ___, found to be in DKA.
She was healthy until early ___ at which time she presented
to ___ with R sided hemiplegia, aphasia, confusion. She
was transferred to ___ and work up included
CT-perfusion, MRI, LP, EEG all of which were inconclusive. It
was determined she'd had a seizure and was discharged ___ on
keppra.
She was readmitted in late ___ with progressive change in
behavior/psychosis at home. During that visit she had extensive
additional w/u ultimately resulting in diagnosis with limbic
encephalitis thought secondary to autoimmune thyroiditis (TPO Ab
were elevated at 62). Of note T4 was normal, TSH was initially
normal and nadired at 0.26.
She was discharged home on a prolonged steroid taper (starting
at 60, decreasing by 5mg every month, currently at 55 mg daily).
She was also discharged on keppra and VPA. She was initially
doing well at home up until the ___ prior to admission when
she developed dizziness, generalized weakness and malaise, and
increased urinationa nd thirst. 3 days prior to admission she
went to ___ ED, was found to have oral thrush, was given
nystatin and sent home. She's not sure if fingerstick or urine
was checked. She continued to feel significant malaise and
thinks she lost 20 lbs due to increased urination and decreased
appetite over this time period.
ROS is notable for dry cough, dysuria. No shortenss of breath,
chest pain, abdominal pain, rash, diarrhea, constipation, or
other symptoms. She was not noted to have any behavioral
changes, confusion, or focal neuro changes at home.
In the ED, she was noted to have a finger stick >500, anion gap
32, bicarb 18, ketones in her urine. UA also notable for 8 WBC.
Neuro was consulted and initiallyr ecommended treatment of UTI
and discharge home (prior to determination that she was in DKA).
She was started on an insulin drip and given 4L NS and
transferred to the FICU.
On arrival to the MICU, fingerstick is 260 and she feels much
better than when she first came in. Still feels very thirsty.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Steroid-responsive encephalopathy
Autoimmune thyroiditis
ANKLE PAIN
TRAPEZIUS PAIN
BACTERIAL VAGINOSIS
FIBROID UTERUS
Hernia repair
Social History:
___
Family History:
Paternal aunt had a stroke at age ___. Mother with HTN, DM, no
CAD; Paternal grandfather with unspecified CA, DM. No family
history of type 1 DM or thyroid disorders as far as she knows.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
HEENT:dry mucus membranes, oral thrush
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: nondistended, +BS, nontender in all quadrants, 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
DISCHARGE PHYSICAL EXAM
=======================
Essentially unchanged from admission exam
Pertinent Results:
ADMISSION LABS
==============
___ 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 11:35AM WBC-9.6# RBC-5.36* HGB-14.8# HCT-47.4*#
MCV-88 MCH-27.6 MCHC-31.2* RDW-16.3* RDWSD-52.0*
___ 11:35AM NEUTS-81.7* LYMPHS-11.8* MONOS-5.9 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-7.81*# AbsLymp-1.13* AbsMono-0.56
AbsEos-0.00* AbsBaso-0.01
___ 11:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:35AM GLUCOSE-529* UREA N-35* CREAT-1.4* SODIUM-143
POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-18* ANION GAP-37*
___ 11:35AM ALT(SGPT)-21 AST(SGOT)-11 ALK PHOS-68 TOT
BILI-0.4
___ 11:35AM ALBUMIN-4.8 CALCIUM-11.2* PHOSPHATE-4.4
MAGNESIUM-3.1*
PERTINENT LABS/MICROBIOLOGY
===========================
___ 07:02PM %HbA1c-11.3* eAG-278*
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-4.2 RBC-4.12 Hgb-11.3 Hct-35.6 MCV-86
MCH-27.4 MCHC-31.7* RDW-15.9* RDWSD-49.8* Plt ___
___ 07:20AM BLOOD Glucose-146* UreaN-17 Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-27 AnGap-13
___ 07:20AM BLOOD Phos-3.6 Mg-2.0
___ 07:02PM BLOOD %HbA1c-11.3* eAG-278*
IMAGING
=======
___ CXR
Frontal and lateral chest radiographs demonstrate a normal
cardiomediastinal silhouette and well-aerated lungs without
focal consolidation, pleural effusion, or pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Propranolol LA 60 mg PO DAILY
3. LamoTRIgine 75 mg PO BID
4. PredniSONE 55 mg PO DAILY
5. Valproic Acid ___ mg PO Q12H
6. Calcium Carbonate 500 mg PO BID
7. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Glargine 30 Units Breakfast
Glargine 30 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic Please check blood sugar as directed
by diabetes nurse three times a day Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 30 Units before
BKFT; 30 Units before BED; Disp #*2 Vial Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 30 Units before
BKFT; 30 Units before BED; Disp #*2 Vial Refills:*0
RX *blood-glucose meter please check blood sugar as directed by
diabetes nurse educator three times a day Disp #*1 Kit
Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 17 Units
QID per sliding scale Disp ___ Milliliter Refills:*0
RX *lancets [Fingerstix Lancets] check blood sugar as directed
by diabetes three times a day Disp #*1 Box Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
31 gauge x ___ Inject insulin as directed by the diabetes
nurse TID for short acting and BID for long-acting Disp #*200
Syringe Refills:*0
3. LamoTRIgine 75 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. PredniSONE 55 mg PO DAILY
6. Propranolol LA 60 mg PO DAILY
7. Valproic Acid ___ mg PO Q12H
8. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
DKA. new diagnosis diabetes
Limbic encephalitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough, on prednisone // pna? infectious workup
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___ and ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and well-aerated lungs without focal consolidation, pleural
effusion, or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 99.0
heartrate: 84.0
resprate: 18.0
o2sat: 98.0
sbp: 130.0
dbp: 98.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with recent admission w/psychosis found to have limbic
encephalitis thought ___ autoimmune thyroiditis, who on
prolonged prednisone taper, who now presents in DKA.
1. DKA, likely steroid induced diabetes: Presented in DKA with
anion gap to 32 on admission and glucose >500. She was started
on insulin gtt, ___ consult was placed, she was given fluid
resuscitation and electrolyte repletion per ICU protocol. She
became hypernatremia to 151 and fluids were changed to ___.
She was given Lantus 20 units then an additional 10 units on
___. Insulin gtt was stopped at 11:00 on ___. She was
transitioned to subQ insulin which was uptitrated by discharge
to 30U lantus BID and 6U TID prandial lispro with additional
ISS. Pt was seen by nutrition and given instructions on low
carb diet. Plan was for patient to see ___ RN for teaching
on ___ but pt left AMA prior to seeing the RN. She was
given a prescription for insulin, syringes, and blood glucose
testing supplies prior to discharge and taught by the floor RN's
on how to inject insulin. ___ follow-up information was
provided to the patient.
2. Autoimmune thyroiditis c/b limbic encephalitis: Neurology
and endocrinology were consulted. She was continued on home
doses of prednisone, lamotrigine, valproate.
3. UTI: Urinalysis with pyuria. She was started on ceftriaxone
and given 2 doses. Urine culture grew mixed bacterial flora. She
was given 1 dose of TMP/SMX to complete 3 day course for simple
UTI.
Billing: greater than 30 minutes was spent on discharge
counseling and coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
L ureteral stent, laser lithotripsy
History of Present Illness:
Patient is a ___ year-old female with a history of multiple renal
calculi since ___ s/p lithotripsy 2 weeks ago for
nephrolithiasis on the left without immediate complication
presenting with acute onset left sided flank pain and hematuria
3 days prior to presentation. The pain radiates around to front
and into groin and is associated with nausea, but no vomiting,
and gross hematuria. Patient contacted her outpatient provider
who felt this was atypical post-procedure course. Because the
pain was worsening, patient presented to the ED.
In the ED, initial vitals were 97.8 111 153/66 20 100%RA. CTU
showed mild to moderate left hydronephrosis due to 2 UPJ stones
up to ___ in diameter and 5 distal ureteral stones. Urology
contacted and recommended pain control and admission to
medicine. Recieved toradol, morphine, zofran and tamsulosin.
This morning on the floor, patient states her pain is improved,
but still present. She still has gross hematuria. She was able
to eat breakfast this morning without any nausea.
Past Medical History:
Psoriasis
Lumbar Disc Disease
Right nephrolithiasis ___
Left nephrolithiasis s/p lithotripsy ___
s/p hysterectomy
diverticulosis
Pancreatic cyst
Social History:
___
Family History:
father ___ prostate ca and rectal cancer
mother with htn
Physical Exam:
ADMISSION PE:
Vitals: 97.7 100-122/50-70 76 16 100% ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly tender in RLQ, right flank and epigastrum,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 12:45PM GLUCOSE-80 UREA N-10 CREAT-0.7 SODIUM-142
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
___ 06:55AM WBC-9.7 RBC-3.47* HGB-10.2* HCT-31.4* MCV-91
MCH-29.5 MCHC-32.5 RDW-12.5
___ 06:55AM PLT COUNT-228
___ 11:02PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:02PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM
___ 11:02PM URINE RBC->182* WBC-11* BACTERIA-FEW
YEAST-NONE EPI-0
___ 11:02PM URINE MUCOUS-RARE
___ 09:36PM GLUCOSE-123* UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
___ 09:36PM estGFR-Using this
___ 09:36PM WBC-15.1*# RBC-4.32 HGB-12.6 HCT-38.6 MCV-89
MCH-29.1 MCHC-32.6 RDW-12.4
___ 09:36PM NEUTS-72.8* ___ MONOS-4.5 EOS-1.1
BASOS-0.5
___ 09:36PM PLT COUNT-300
Medications on Admission:
none
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
4. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for bladder pain/spasm.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
L ureterolithiasis
Discharge Condition:
Stable
A/Ox3
Independent
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of stone burden. Left-sided steinstrasse with ESWL
performed.
COMPARISON: CTU ___.
FINDINGS: Supine and upright abdominal radiographs demonstrate a left
ureteral stent terminating in the bladder. There is a 4-mm calculus in the
proximal ureter as well as a 7-mm calculus in the lower pole of left kidney,
corresponding to prior CT. No distal or right-sided renal calculi are
visualized. The bowel gas pattern is non-specific. The lung bases are clear.
There is no evidence of obstruction or ileus.
IMPRESSION: Residual 4-mm calculus in the proximal left ureter and 7-mm
calculus in the lower pole of the left kidney.
Radiology Report
INDICATION: Left stent placement.
FINDINGS: Four intraoperative fluoroscopic images were submitted for
documentation without a radiologist present. A left ureteral stent is noted
with several filling defects in the mid and distal left collecting system.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEMATURIA
Diagnosed with CALCULUS OF URETER
temperature: 97.8
heartrate: 111.0
resprate: 20.0
o2sat: 100.0
sbp: 153.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a pleasant ___ recently s/p L ESWL for large renal
stone burden initally presenting to ED with intractable flank
pain and nausea. She was admitted to the medicine service for
acute management of pain. As part of primary evaluation, imaging
was obtained demonstrating two segments of her left ureter with
evidence of steinstrasse. Given the acute condition, she was
transferred to the urology service on HD1 for further evaluation
and management. Her pain was controlled by ___ of HD1 and pt no
longer experiencing nausea. Preliminary plans for Perc drainage
were aborted givent he patients signifcant improvement in
clinical condition. On ___ of HD 1 pt was taken to OR for stent.
Please see operative note for further details. Patient recovered
uneventfully overnight. She was discharged on HD2 afebrile with
stable vital signs, well controlled pain, tolerating po without
nausea or emesis. She demonstrated good understanding of her
post operative instructions for further managmenet of her stone
disease. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / lisinopril
Attending: ___.
Chief Complaint:
Diarrhea, dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ PMH history of dementia, HTN, HLD, Crohn's disease
with history of SBOs presenting with diarrhea.
Patient reports that she has been having watery brown diarrhea
over the last three days accompanied by nausea, vomiting and
crampy abdominal pain in both lower quadrants. She also has been
having fatigue and lightheadedness of one day. She reports that
there has been a norovirus outbreak at her facility. No fevers,
chills, chest pain, SOB, melena or hematochezia. Of note the
patient's daughter reports she has been off her Crohn's
medications for several days.
In the ED, initial vitals: T 98 BP 123/80 RR 16 O2 sat 98% on
room air
- Exam notable for:
General: Well appearing, no acute distress
HEENT: Dry mucous member
Cardiac: RRR , no chest tenderness
Pulmonary: Clear to auscultation bilaterally with good aeration,
no crackles/wheezes
Abdominal/GI: Normal bowel sounds, no tenderness or masses
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: Sensation intact upper and lower extremities, strength
___
upper and lower, CN II-XII intact
Psych: Normal judgment, mood appropriate for situation
- Labs WNL
- Imaging notable for: CT abdomen pelvis:
1. Similar distribution of inflammatory bowel disease involving
severalsegments of the distal ileum with intervening skip
segments. The degree of disease activity is difficult to
precisely assess on this exam, though appears mildly active and
overall improved in the interval, without evidence for abscess,
bowel obstruction, or fistula.
2. Small pneumobilia, new in the interval. Correlate with any
history of sphincterotomy.
3. Unchanged sub 6 mm bilateral pulmonary nodules.
4. Dilated left gonadal vein and prominent left-sided pelvic
varices can be seen with pelvic congestion syndrome in the
correct clinical setting, unchanged.
- Pt given: 2L NS, Atorvastatin 20mg, mesalamine 2g
- Vitals prior to transfer: T 98.2 heart rate 81 BP 103/71 RR 16
O2 sat 97% on room air
Upon arrival to the floor, the patient reports she feels mildly
improved after arriving to the hospital. She continues to have
diarrhea ___ times a day and is extremely thirsty.
Past Medical History:
- Hypertension
- Hypercholesterolemia
- Crohn's disease, small bowel involvement, followed by Dr.
___
- Osteopenia
- Melanoma status post wide excision to tibia ___ yrs ago
- Migraines
- Alzheimers Disease
- hypothyroidism
Social History:
___
Family History:
Mother: COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 232)
Temp: 97.8 (Tm 97.8), BP: 158/84, HR: 81, RR: 17, O2 sat:
95%, O2 delivery: RA, Wt: 140 lb/63.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, dry mucus membranes, oropharynx clear,
EOMI, PERRL
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, normoactive bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Oriented to ___, ___.
DISCHARGE PHYSICAL EXAM:
VS: ___ 1101 Temp: 97.7 PO BP: 119/68 R Lying HR: 56 RR: 18
O2 sat: 95% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx
clear, EOMI, PERRL
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, normoactive bowel
sounds present, no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Pertinent Results:
ADMISSION LABS:
___ 02:02PM BLOOD WBC-4.7 RBC-4.20 Hgb-11.2 Hct-35.6 MCV-85
MCH-26.7 MCHC-31.5* RDW-13.4 RDWSD-41.6 Plt ___
___ 02:02PM BLOOD Neuts-79.0* Lymphs-11.5* Monos-8.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.72 AbsLymp-0.54*
AbsMono-0.41 AbsEos-0.01* AbsBaso-0.01
___ 02:02PM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-143 K-4.1
Cl-105 HCO3-25 AnGap-13
___ 02:04PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 07:25AM BLOOD WBC-4.5 RBC-4.03 Hgb-10.7* Hct-33.7*
MCV-84 MCH-26.6 MCHC-31.8* RDW-13.2 RDWSD-40.0 Plt ___
___ 07:25AM BLOOD Glucose-88 UreaN-15 Creat-0.7 Na-142
K-4.1 Cl-105 HCO3-24 AnGap-13
___ 07:25AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
CT ABD & PELVIS WITH CONTRAST
IMPRESSION:
CT abdomen pelvis:
1. Similar distribution of inflammatory bowel disease involving
severalsegments of the distal ileum with intervening skip
segments. The degree of disease activity is difficult to
precisely assess on this exam, though appears mildly active and
overall improved in the interval, without evidence for abscess,
bowel obstruction, or fistula.
2. Small pneumobilia, new in the interval. Correlate with any
history of sphincterotomy.
3. Unchanged sub 6 mm bilateral pulmonary nodules.
4. Dilated left gonadal vein and prominent left-sided pelvic
varices can be seen with pelvic congestion syndrome in the
correct clinical setting, unchanged.
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. Atenolol 50 mg PO DAILY
4. Atenolol 25 mg PO QHS
5. Atorvastatin 20 mg PO QPM
6. Cyanocobalamin ___ mcg PO 3X/WEEK (MO,WE,SA)
7. Donepezil 5 mg PO QHS
8. LevETIRAcetam 250 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Mesalamine 1000 mg PO BID
11. Pantoprazole 40 mg PO BREAKFAST
12. Pyridoxine 100 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Co Q-10 (coenzyme Q10) 300 mg oral BID
15. digestive enzymes 1 T oral QIDACHS
16. Famotidine 20 mg PO QHS
17. Acidophilus Probiotic Blend (L.acidoph,saliva-B.bif-S.therm)
175 mg oral DAILY
18. Gemfibrozil 600 mg PO DAILY
19. LORazepam 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Acidophilus Probiotic Blend (L.acidoph,saliva-B.bif-S.therm)
175 mg oral DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Atenolol 25 mg PO QHS
6. Atorvastatin 20 mg PO QPM
7. Co Q-10 (coenzyme Q10) 300 mg oral BID
8. Cyanocobalamin ___ mcg PO 3X/WEEK (MO,WE,SA)
9. digestive enzymes 1 T oral QIDACHS
10. Donepezil 5 mg PO QHS
11. Famotidine 20 mg PO QHS
12. Gemfibrozil 600 mg PO DAILY
13. LevETIRAcetam 250 mg PO BID
14. Levothyroxine Sodium 75 mcg PO DAILY
15. LORazepam 0.5 mg PO DAILY:PRN anxiety
16. Mesalamine 1000 mg PO BID
17. Pantoprazole 40 mg PO BREAKFAST
18. Pyridoxine 100 mg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with Crohn's disease here with diarrhea. Has missed several
days of her Crohn's medication last week.+PO contrast// Crohn's flare.
Intra-abdominal pathology such as diverticulitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 13.0 mGy (Body) DLP = 658.4
mGy-cm.
Total DLP (Body) = 667 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields demonstrate several pulmonary nodules
measuring up to 4 mm, unchanged. Otherwise, there is no focal consolidation.
There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A small air locule is seen within the right hepatic lobe likely
reflective of pneumobilia (___). Otherwise, 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: A small hiatal hernia is present. Otherwise, the stomach is
unremarkable. There is circumferential wall thickening, associated luminal
narrowing, engorgement of mesenteric vessels, and mucosal hyperemia involving
several segments of the distal ileum in a similar pattern of distribution with
intervening skip segments as compared to the previous CT consistent with Crohn
disease. While the degree of disease activity is difficult to assess on this
exam, the extent of inflammation appears mild and somewhat improved in the
interval (601:18). There is no evidence of bowel obstruction, fluid
collections, fistula formation, or pneumoperitoneum. Sigmoid diverticulosis
without signs of diverticulitis is again demonstrated. The rectum and colon
are unremarkable with oral contrast seen in the rectum. The appendix is not
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: Multiple prominent mesenteric lymph nodes are demonstrated.
Otherwise, there is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Dilated left gonadal vein with prominent left-sided pelvic varices
are present. There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Multilevel degenerative changes of thoracolumbar spine are
demonstrated. There is a grade 1 anterolisthesis of L4 over L5, unchanged.
Otherwise, there is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Similar distribution of inflammatory bowel disease involving several
segments of the distal ileum with intervening skip segments. The degree of
disease activity is difficult to precisely assess on this exam, though appears
mildly active and overall improved in the interval, without evidence for
abscess, bowel obstruction, or fistula.
2. Small pneumobilia, new in the interval. Correlate with any history of
sphincterotomy.
3. Unchanged sub 6 mm bilateral pulmonary nodules.
4. Dilated left gonadal vein and prominent left-sided pelvic varices can be
seen with pelvic congestion syndrome in the correct clinical setting,
unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Dizziness
Diagnosed with Dizziness and giddiness, Diarrhea, unspecified, Dehydration
temperature: 98.0
heartrate: 73.0
resprate: 16.0
o2sat: 98.0
sbp: 123.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | ___ yo F w/ ___ history of dementia, HTN, HLD, Crohn's disease
with history of SBOs presenting with diarrhea.
#Acute viral gastroenteritis
Presented with several days of diarrhea, nausea and vomiting
from nursing facility that has a confirmed outbreak of
norovirus. Of note, last admission was also secondary to
norovirus. S/p ___ L of fluid in the ED + additional 1L IVF on
floor. Diarrhea self-resolved. No nausea or abdominal pain
during this admission. C. diff negative. Norovirus PCR negative
but suspect that this self-limited episode was caused by a
different viral gastroenteritis. Had a soft formed, non-bloody
bowel movement on day of discharge.
#Crohn's disease
Followed by Dr. ___ mid small bowel. Per family
patient recently missed 3 days of medications prior to
admission. CRP elevated at 52.6 on admission. CT abd/pelvis
demonstrated IBD involving several segments of the distal ileum
with intervening skip segments similar to prior imaging, disease
appears mildly active and overall improved in the interval. No
evidence of abscess, bowel obstruction, or fistula on imaging.
Per Dr. ___ has not had any true recent flares and
does not have involvement of colon so diarrhea would be unusual.
Overall, pt's diarrhea is more likely due to viral
gastroenteritis, as above, than Crohn's flare. Continued home
mesalamine (home medication Pentasa 500mg capsules --> takes 2
capsules BID equivalent of 4g).
#Dementia
Pt has diagnosis of early Alzheimer's disease. This admission
she believed that someone told her she had a new cancer
diagnosis, and also believed that she was "left in a cellar"
during a night when she did not leave her room. Per her
daughter, she appeared to be more confused than usual during
this admission, may be due to delirium or sundowning in addition
to baseline dementia. Continued home donepezil, talking with
family very helpful. Was seen by ___ and OT while admitted and
was cleared for discharge back to ___.
#Pneumobilia
Noted incidentally on CT scan with no recent biliary
instrumentation. Unclear if represents infection vs. other
etiology, reassuringly without abdominal pain throughout
admission. LFTs with slightly increased alk phosph, otherwise,
reassuring.
C - Chronic issues pertinent to admission
==================================
# Hyperlipidemia
Continued home atorvastatin, Gemfibrozil.
# Hypertension
Continued home atenolol, amlodipine.
# Primary prevention
Continued home aspirin.
# Hypothyroidism
Continued home levothyroxine.
# Partial seizures
Continued home Keppra.
# GERD
Continued home PPI, H2 blocker.
T - Transitional Issues
==================================
[] F/u pending stool studies: microsporidia stain, cyclospora
stain, ova and parasites, cryptosporidium/giardia DFA. Given
episode resolved, these are unlikely to be positive.
[] Consider transitioning atenolol to carvedilol as outpatient.
Atenolol is renally cleared and can accumulate in cases of acute
renal failure leading to toxicity.
[] Small Pneumobilia: seen incidentally on CT A/P in the absence
of any abdominal pain or infectious symptoms outside of
self-limited diarrhea. No evidence of gallbladder fistula on CT,
no history of sphincterotomy in past. If develops abdominal pain
or fever/chills, low threshold to reimage.
[] Had elevated CRP to 53 on admission but per discussion with
her outpatient GI specialist, unlikely to be a Crohn's flare.
Has f/u with GI in 2 weeks.
#CODE: Full (presumed)
#CONTACT
___
Relationship: Daughter
Phone number: ___
>30 minutes spent on complex discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan / carvedilol / amlodipine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ Female with ESRD (s/p LURT ___ on
immunosuppression), anemia (weekly transusions and epo
injections), CAD s/p ___ 4 (most recently ___, HFrEF (55%
EF ___, HTN, T1DM (A1c 9.9% ___, and h/o multiple MDR
UTIs (Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
chart history antiphospholipid antibody syndrome (but on
evaluation by hematology does not appear to meet diagnostic
criteria) with h/o remote PE in ___, presenting with 3
witnessed
pre-syncopal episodes.
Reports was sitting on the couch - feeling nauseated, and tired,
and lightheaded. Reports most of the afternoon wasn't feeling
well. Report tried to get up to go to the bathroom but couldn't
make it bc was getting really disoriented and dizzy and felt
like
she was going to pass out. Reports around 5 pm daughter was
trying to help her. Tried on rollator and kept slumping over,
feeling transiently out of it, not responding. She denies losing
consciousness during these episodes. Reports 3 episodes of
slumping over. Denies chest pain, palpitations. Reports feels
similar to when had orthostatic episodes in the past. Reports
was
feeling SOB when was trying to get into bed. She did not feel
chest tightness or pain. She was not diaphoretic.
Reports when woke up this morning took BP and was 130/65 which
is
low for her. Reports skipped metoprolol this morning from the
low
bp and all day every time stood up was so lightheaded. Denies
cough. Reports has issue with vomiting but this has been at her
baseline; she has not seen blood in her vomitus. Denies BRBPR or
melena. Reports saw cardiology on ___ and was put back on 20
mg lasix daily. Denies SOB now, chest pain.
Of note, the pt reports she is also being worked up for a 4 cm
pancreatic mass with plans for biopsy in ___ once she can stop
taking DAPT (6 mos after her DES). She also reports that she has
been increasingly pruritic and that family members have noted
that she appears to have a more yellow complexion. She has also
had a 20 pound unintentional weight loss.
Past Medical History:
-CAD - Percutaneous Coronary Interventions: LAD PTCA; s/p PTCA
___ DES to LAD and Cx/OM ___ DES to LAD ___
PCI of Cx and OM with ___
-___ renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
-Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catheterization)
-Hypertension
-Dyslipidemia
-Scleroderma w/ CREST syndrome
-Gastroparesis/GERD/Hiatal hernia
-Gout diagnosed ___ years ago
-OSA
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
Sister - Kidney cancer
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Father - alcohol use disorder
Physical Exam:
ADMISSION EXAM:
==============
GENERAL: Yellow complexion, NAD
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Jaundiced, warm and well perfused, no excoriations or
lesions, no rashes
DISCHARGE EXAM;
=============
Temp: 98.9 (Tm 98.9), BP: 160/75 (96-175/60-107), HR: 94
(80-96),
RR: 20 (___), O2 sat: 97% (96-100)
GENERAL: Lying comfortably in bed
HEENT: AT/NC, EOMI, PERRL, scleral icterus present, pink
conjunctiva, MMM, no sublingual icterus noted
NECK: supple, no LAD, no JVD
HEART: RRR, normal S1 and S2, II/VI holosystolic murmur, no
gallops or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: BS+, distended abdomen without fluid wave, mildly TTP
in
supraumbilical and suprapubic regions, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
-------------------
___ 07:05PM BLOOD WBC-8.1 RBC-1.91* Hgb-5.8* Hct-17.9*
MCV-94 MCH-30.4 MCHC-32.4 RDW-18.6* RDWSD-61.7* Plt ___
___ 07:05PM BLOOD Glucose-288* UreaN-68* Creat-2.3* Na-138
K-3.6 Cl-109* HCO3-16* AnGap-13
___ 07:05PM BLOOD CK-MB-4 ___
___ 07:05PM BLOOD Calcium-7.7* Phos-3.6 Mg-1.5*
RADIOLOGY:
Transplant US ___:
The left 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
hydronephrosis and no perinephric fluid collection.
No diastolic flow is detected within the intrarenal arteries
with a resistive
index of 1.0. The main renal artery shows an abnormal waveform,
with prompt
systolic upstroke but without continuous diastolic flow. Peak
systolic
velocity of 51.8 centimeters/second is seen in the main renal
artery.
Vascularity is symmetric throughout transplant. The transplant
renal vein is
patent and shows normal waveform.
IMPRESSION:
1. No diastolic flow within the intrarenal arteries with
resistive index of 1,
new since ___ with lack of continuous diastolic flow
within the main
renal artery.
2. Patent main renal vein.
3. No hydronephrosis or perinephric fluid collection.
MICRO:
Urine culture: No growth
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-6.4 RBC-2.86* Hgb-8.8* Hct-26.2*
MCV-92 MCH-30.8 MCHC-33.6 RDW-18.1* RDWSD-59.3* Plt ___
___ 05:00AM BLOOD ___ PTT-28.6 ___
___ 05:00AM BLOOD Glucose-433* UreaN-71* Creat-2.5* Na-138
K-4.8 Cl-109* HCO3-18* AnGap-11
___ 05:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
___ 09:35AM BLOOD Cyclspr-68*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. melatonin 10 mg oral QHS
2. naftifine 2 % topical BID To soles of feet and between toe
webs
3. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Calcium Carbonate 500 mg PO BID
10. Cilostazol 25 mg PO QPM
11. Cilostazol 50 mg PO QAM
12. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
13. Ferrous Sulfate 325 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Furosemide 20 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Multivitamins 1 TAB PO DAILY
19. Mycophenolate Mofetil 500 mg PO BID
20. Omeprazole 40 mg PO BID
21. PredniSONE 5 mg PO DAILY
22. Promethazine 25 mg PO TID:PRN nausea
23. Ranolazine ER 500 mg PO BID
24. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
25. ___ SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
26. trimethobenzamide 300 mg oral TID:PRN nausea
27. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Cilostazol 25 mg PO QPM
7. Cilostazol 50 mg PO QAM
8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H
9. Ferrous Sulfate 325 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Levothyroxine Sodium 125 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. melatonin 10 mg oral QHS
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Mycophenolate Mofetil 500 mg PO BID
17. naftifine 2 % topical BID To soles of feet and between toe
webs
18. Omeprazole 40 mg PO BID
19. PredniSONE 5 mg PO DAILY
20. Promethazine 25 mg PO TID:PRN nausea
21. Ranolazine ER 500 mg PO BID
22. Senna Plus (sennosides-docusate sodium) 8.6-50 mg oral
BID:PRN constipation
23. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis
24. Toujeo SoloStar U-300 Insulin (insulin glargine) 24 units
subcutaneous QAM
25. trimethobenzamide 300 mg oral TID:PRN nausea
26. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Anemia of chronic inflammation
Secondary diagnosis:
- End stage renal disease s/p renal transplant
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: RENAL TRANSPLANT U.S.
INDICATION: ___ year old woman s/p renal transplant now with ___//
?Hydronephrosis, ?flow to transplant
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: ___ renal ultrasound
FINDINGS:
The left 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
hydronephrosis and no perinephric fluid collection.
No diastolic flow is detected within the intrarenal arteries with a resistive
index of 1.0. The main renal artery shows an abnormal waveform, with prompt
systolic upstroke but without continuous diastolic flow. Peak systolic
velocity of 51.8 centimeters/second is seen in the main renal artery.
Vascularity is symmetric throughout transplant. The transplant renal vein is
patent and shows normal waveform.
IMPRESSION:
1. No diastolic flow within the intrarenal arteries with resistive index of 1,
new since ___ with lack of continuous diastolic flow within the main
renal artery.
2. Patent main renal vein.
3. No hydronephrosis or perinephric fluid collection.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:07 pm, 1 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 97.3
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 118.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ woman with transfusion-dependent anemia on epo, CAD
s/p DESx4 (most recent ___, HFrEF (EF now 55%), ESRD ___
T1DM s/p LURT PMH HFrEF (EF 41%), ESRD ___ T1DM s/p LURT ___
(on cellcept, prednisone, and cyclosporine), CREST/systemic
sclerosis and dysautonomia with orthostatic hypotension who
presented with presyncope, found to be profoundly anemic. She
was transfused and volume resuscitated with normalization of her
orthostatic vital signs and was discharged home with close
heme/onc follow up.
ACUTE ISSUES:
===============
#Syncope: The patient's symptoms and presentation all seemed
most consistent with orthostasis, particularly given orthostatic
VS on check ___. However, given her extensive cardiac history
including a recent MI, she was a monitored on telemetry for
evidence of arrhythmia. Her telemetry remained without any
events. She was volume resuscitated gently given her history of
heart failure. Her orthostatic vital signs were trended and
ultimately normalized after IVF and PRBCs.
# Type II NSTEMI: The patient had a troponin of 0.2 on admission
which downtrended to 0.___K-MB. She did not
complain of any chest pain or anginal symptoms on admission. In
the setting of her acute anemia (discussed below) she did have
some EKG changes including ST segment depressions in her lateral
precordial leads. However, with the resolution of her underlying
anemia her EKG changes resolved. Her home regimen consisting of
ASA 81mg daily, Ticagrelor 90mg BID, Ranolazine 500mg ER BID,
cilostazole 100mg qAM, 50mg qPM was continued on discharge. No
statin due to interaction with immunosuppression.
#Anemia: The patient's baseline Hgb is ___. Iron studies
conducted on previous admission suggest anemia of chronic
inflammation; reduced renal function and low epo also likely
cause. She is being followed closely as an outpatient by
heme/onc, and is currently getting weekly transfusions of one
unit of packed red blood cells and epo. She had no signs of
active bleeding during her hospitalization, and her Hgb remained
stable following the transfusion of two units of pRBCs.
#Pancreatic mass
The patient has a known pancreatic mass detected on abd CT
___ s/p fall. Pt awaiting biopsy in ___ mos s/p ___
___ when she can stop DAPT. Very concerning for malignancy
given pt reporting full body pruritus, unintentional weight
loss, malaise, early satiety, and gnawing abdominal pain. LFTs
not concerning right now for any obstructive process.
#HFrEF: LVEF 55% on admission in ___, recovered from 40%. At
that time discharged on Lasix 40mg PO BID, Metoprolol succinate
50mg PO daily, Hydralazine 50mg PO BID. Her weight on discharge
was 56.97, which is her current admit weight. On this admission,
she displayed no signs/sx of volume overload. Her lasix was held
on admission given her recent syncopal episodes. Ultimately, her
discharge heart failure regimen was as follows:
#Pyuria
The patient has a history of MDR UTIs. Her urine culture was
negative on admission and she was not treated with antibiotics.
CHRONIC ISSUES:
===============
#ESRD s/p Transplant: Ongoing CKD likely related to poorly
controlled T1DM. Discharge creatinine was 2.5.
# DM1:
Poorly controlled, most recent A1c 9.9% at ___ on ___,
with multiple sequelae. Patient was hyperglycemic during her
hospital stay while off her home ___, however on the day
prior to discharge was transitioned to 25u of glargine with
better control of her sugars. At discharge her home insulin
regimen was continued.
# Hypothyroidism: Continued on home levothyroxine
# Gout: Continued on home allopurinol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Back pain, delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of HTN and chronic LBP ___ scoliosis who p/w acute on
chronic worsening of LBP.
For her LBP, she takes tramadol prn ___ pills of 50 mg qhs) as
well rhizotomy (radiofrequency therapy) which she has had 2
treatments.
In the ED, initial vitals were: Afebrile, HR 85, BP 180s/80s, RR
16, RA
Exam notable for writhing in pain, tachycardic, no midline back
pain.
Labs notable for cr 0.8, wbc 10.4
Imaging notable for CXR without widening and CTA without signs
of dissection.
Patient was given given IV morphine 2 mg x2, Ativan 1 mg IV, and
500 mL NS. She became acutely agitated and combative after
administration of those medications.
She was admitted for delirium.
On the floor, speaking to her and her daughter, she endorses
acute on chronic worsening LBP. No history of CVA/MI/clots. No
history of dementia, but has mild cognitive impairment.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
Scoliosis
Breast cancer s/p lumpectomy ___ years ago with radiation
Social History:
___
Family History:
Father died of a stroke and mother died when she was ___. No
history of MI, clots, or cancer in family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.7, BP 149/75, HR 75, RR 20, 98% 1 lpm NC
Gen: Sleepy, but alert and answers questions when asked
HEENT: Pupils pinpoint, but reactive to light. Dry mucus
membranes
CV: ___ SEM RUSB nonradiating. Regular rhythm.
Pulm: CTAB, no w,r,r
Abd: NTTP, normal bowel sounds, nondistended
GU: No foley
Ext: No lower extremity edema, warm distal extremities
Skin: Echymoses bilateral upper and lower extremities
Neuro: A+Ox2 (knows name, year, hospital, but not month or day
of week). CN II-XII intact. ___ strength bilateral wrist
extensors/flexors, lumbricals, biceps/triceps, deltoids, hips,
ankle extensors/flexors
Psych: Pleasant and cooperative
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.7, BP 154/81, HR 78, RR 20, 96% room air
Gen: Mildly anxious, sitting on bed and shaking right leg
HEENT: PERRL, MMM
CV: ___ SEM RUSB nonradiating. Regular rhythm.
Pulm: CTAB, no w,r,r
Abd: NTTP, normal bowel sounds, nondistended
GU: No foley
Ext: No lower extremity edema, warm distal extremities
Back: Prominent scoliotic back, nontender to palpation, no
vertebral step off or concerning skin changes
Skin: Echymoses bilateral upper and lower extremities
Neuro: A+Ox3 and able to say days of week backwards. CN II-XII
intact. ___ strength bilateral wrist extensors/flexors,
lumbricals, biceps/triceps, deltoids, hips, ankle
extensors/flexors. Walking around without gait abnormalities.
Psych: Pleasant and cooperative, but mildly anxious
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:20AM BLOOD WBC-10.4* RBC-3.75* Hgb-12.4 Hct-39.0
MCV-104* MCH-33.1* MCHC-31.8* RDW-12.7 RDWSD-48.1* Plt ___
___ 04:20AM BLOOD Neuts-55.3 ___ Monos-10.2 Eos-1.2
Baso-0.4 Im ___ AbsNeut-5.77 AbsLymp-3.36 AbsMono-1.06*
AbsEos-0.12 AbsBaso-0.04
___ 04:20AM BLOOD ___ PTT-28.9 ___
___ 04:20AM BLOOD Glucose-110* UreaN-25* Creat-0.8 Na-138
K-3.7 Cl-100 HCO3-22 AnGap-20
___ 04:20AM BLOOD ALT-28 AST-27 AlkPhos-78 TotBili-0.2
___ 03:50AM URINE Color-Straw Appear-Clear Sp ___
___ 03:50AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
___ 03:50AM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:54AM URINE CastHy-1*
MICRO LABS:
===========
Urine culture x2 (___): Negative
IMPORTANT IMAGES/STUDIES:
=========================
CXR (___): No mediastinal widening or focal consolidation.
CTA chest (___): 1. No evidence of aortic dissection. 2.
Extensive atherosclerotic disease as detailed above. 3.
Intermediate density rounded lesion measuring 1.4 cm in the
lower pole of the left kidney. Non urgent renal ultrasound is
recommended for further characterization. 4. Thoracic aortic
aneurysm measuring up to 3.8 cm across maximal diameter. 5. Two
4 mm solid pulmonary nodules in the right middle lobe.
Correlation with prior imaging to document stability is
recommended. If not available, chest CT in 12 months is
recommended if patient has elevated risk factors for lung
cancer.
RECOMMENDATION(S):
1. Non urgent returned ultrasound is recommended for further
characterization.
2. 2 4 mm solid pulmonary nodules in the right middle lobe
should be
correlated with any prior imaging, if available to document
stability. If not available, chest CT in 12 months is
recommended if patient has elevated risk factors for lung
cancer.
LABS ON DISCHARGE:
==================
___ 07:25AM BLOOD WBC-5.6 RBC-3.55* Hgb-11.8 Hct-37.0
MCV-104* MCH-33.2* MCHC-31.9* RDW-12.7 RDWSD-49.1* Plt ___
___ 07:25AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-142
K-3.5 Cl-104 HCO3-24 AnGap-18
___ 07:25AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Vitamin B Complex 1 CAP PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Cyclobenzaprine 10 mg PO BID:PRN back pain
6. Tolterodine 2 mg PO DAILY
7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
8. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*2
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply to back once a day Disp #*30 Patch
Refills:*1
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Tolterodine 2 mg PO DAILY
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
7. Valsartan 80 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. HELD- Cyclobenzaprine 10 mg PO BID:PRN back pain This
medication was held. Do not restart Cyclobenzaprine until your
doctor says it is alright
Discharge Disposition:
Home
Discharge Diagnosis:
Acute toxic encephalopathy
Lower Back Pain
Hypertension
Abnormal findings on CT lung and kidney
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with acute back pain // eval for widened
mediastinum
TECHNIQUE: Upright frontal view of the chest
COMPARISON: None available
FINDINGS:
Levoscoliosis of the thoracolumbar spine is noted.
There is no evidence of medius widening. Lung volumes are low. There is
crowding of the bronchovascular structures. There is no focal consolidation,
pneumothorax, or pleural effusion. Cardiomediastinal silhouette is within
normal limits. There is no acute osseous abnormality. There is no free air
underneath the hemidiaphragms.
IMPRESSION:
No mediastinal widening or focal consolidation.
NOTIFICATION: No mediastinal widening or focal consolidation.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: History: ___ with history of back pain p/w sudden worsening of
severe back pain // eval for dissection
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) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 7.9 s, 62.1 cm; CTDIvol = 8.7 mGy (Body) DLP = 541.3
mGy-cm.
Total DLP (Body) = 555 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR: There is no evidence of aortic dissection. There is a thoracic
ascending aortic aneurysm measuring 3.9 cm across maximal diameter (03:52)
There is extensive atherosclerotic disease of the infrarenal aorta. There is
no evidence of significant stenosis at the takeoff of the celiac, SMA, and
___. The celiac axis, SMA, bilateral renal veins are patent. There is
moderate atherosclerotic disease of the bilateral common, external, and
internal iliac arteries.
CHEST:
Neck: There is a 4 mm hypoattenuated nodule in the right lobe of the thyroid
(03:17).
Lymph nodes: There is no axillary, supraclavicular, mediastinal, or hilar
lymphadenopathy.
Pericardium: There is no pericardial effusion. Heart size is top normal.
Lungs: Lung fields are sub-optimally evaluated due to respiratory motion.
There are 2 nodules in the right middle toe measuring 4 mm each (3:63, 65)
There is moderate dependent atelectasis in the bilateral lower lobes. There
is atelectasis in the anti dependent portions of the right middle lobe
atelectasis (03:48). Airways are patent to the subsegmental levels. There is
no pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a irregular hypoattenuated lesion measuring up to 7 mm in segment II
(3:90) which is too small to characterize but statistically likely represents
a simple cyst or biliary hamartoma. There is no intra or extrahepatic biliary
dilatation. The gallbladder is within normal limits, without stones or
gallbladder wall thickening.
PANCREAS: The pancreas is normal without ductal dilatation or focal lesion.
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 intermediate density rounded lesion measuring 1.4 x 1.0 cm (3:99)
the lower pole of the left kidney. There is no hydronephrosis or perinephric
abnormality. A left-sided extrarenal pelvis is noted.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits.
Appendix contains air, has normal caliber without evidence of fat stranding.
There is no evidence of mesenteric lymphadenopathy.
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 uterus is atrophic
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are noted worst in the lumbar spine. Significant
levoscoliosis centered around a T12 vertebral body is noted.
SOFT TISSUES: There is a small fat containing umbilical hernia.
IMPRESSION:
1. No evidence of aortic dissection.
2. Extensive atherosclerotic disease as detailed above.
3. Intermediate density rounded lesion measuring 1.4 cm in the lower pole of
the left kidney. Non urgent renal ultrasound is recommended for further
characterization.
4. Thoracic aortic aneurysm measuring up to 3.8 cm across maximal diameter.
5. Two 4 mm solid pulmonary nodules in the right middle lobe. Correlation
with prior imaging to document stability is recommended. If not available,
chest CT in 12 months is recommended if patient has elevated risk factors for
lung cancer.
RECOMMENDATION(S):
1. Non urgent returned ultrasound is recommended for further characterization.
2. 2 4 mm solid pulmonary nodules in the right middle lobe should be
correlated with any prior imaging, if available to document stability. If not
available, chest CT in 12 months is recommended if patient has elevated risk
factors for lung cancer.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: UPPER AND LOWER BACK PAIN
Diagnosed with Other dorsalgia, Low back pain
temperature: 97.9
heartrate: 85.0
resprate: 16.0
o2sat: 99.0
sbp: 182.0
dbp: 86.0
level of pain: 10
level of acuity: 2.0 | This is an ___ year old female with past medical history of
hypertension, chronic lower back pain attributed to scoliosis
who presented to ___ ED with worsening of lower back pain, and
was subsequently admitted for altered mental status thought to
be secondary to medication effect, resolved and able to be
discharged home
# Acute toxic encephalopathy - Patient presented to the ED with
acute on chronic worsening of her back pain without new
neurologic deficits. In the ED, she underwent a CTA torso which
did not show any acute abnormalities. ED course was
notable for receipt of morphine 2 mg IV x2 and Ativan 1 mg IV.
She subsequently became acutely agitated and delirious and was
admitted to the medicine service. Infectious and metabolic
workups were without positive findings. Her mental status
improved back to baseline over the subsequent 12 hours, verified
by her husband who was at the bedside. They believed that
recently initiated outpatient cyclobenzaprine also contributed.
# Lower back pain - no focal neurologic deficits. Pain control
complicated as above. Once mental status improved to baseline,
patient reported her symptoms were at baseline. She was
discharged with recommendations to use lidocaine patch and
Tylenol, and avoid sedating medications. At patient's request
cyclobenzaprine was recommended to be held pending PCP ___
and discussion.
#Hypertension: She was continued on her home valsartan 80 mg qd.
#Hyperlipidemia: She was continued on her home atorvastatin 10
mg qd.
#Primary prevention: She was continued on her home aspirin 81 mg
qd.
#Nutrition: She was continued on her home vitamin B complex and
vitamin D |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
___ Complaint:
Fevers, Nausea, Emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Colorectal Surgery Consult Note:
HPI: ___ hx Crohn's disease now ~1 month s/p robotic
proctocolectomy with J pouch and diverting ileostomy recently
admitted for ___ managed conservatively and last seen in clinic
___ without complaints, now 5d s/p pouch study notable for
small leak into the presacral space measuring
~3mm(diam)x32mm(length). Presents to our ED with 24h nausea,
fever to 102, and 1 episode of emesis undigested food. Seen by
___ and directed to ED.
Denies changes in ileostomy output or character, maintaining
~700cc daily output of semi-formed greenish output, abdominal
distention or pain, increased rectal drainage. No motility
agents, no immodium.
Pouchogram ___ notable for leak at the very inferior end
of
the pouch extending into the presacral space, channel measuring
3
mm by 32mm.
At time of consultation, pt AFVSS, benign abdominal exam, DRE
deferred given J pouch with known leak, ileostomy healthy
appearing with gas in bag, WBC 8.9, negative CXR/UA.
Past Medical History:
Past Medical History:Crohn's disease (diagnosed in ___, now
suspect UC, bipolar affective disorder, Hep C cirrhosis, h/o
polysubstance abuse, anxiety
Past Surgical History:robotic proctectomy J pouch and diverting
loop ___ ___, lap total abdominal colectomy, end
ileostomy ___, ___
Social History:
___
Family History:
Mother: arthritis.
Father: HTN
Brother is an alcoholic
grandmother is an alcoholic with history of pancreatic cancer,
grandfather coronary artery disease, cousin mental illness.
Physical Exam:
General: Appears very well, ambulating, tolerating a regular
diet, no pain, denies nausea, no vomiting, slight anxiety
VSS
Abd: flat/soft, ileostomy w output
Pertinent Results:
___ 07:15AM BLOOD WBC-6.0# RBC-4.47* Hgb-12.0* Hct-35.5*
MCV-79* MCH-26.7* MCHC-33.7 RDW-14.5 Plt ___
___ 07:15AM BLOOD WBC-3.6*# RBC-3.96* Hgb-10.6* Hct-31.5*
MCV-80* MCH-26.7* MCHC-33.7 RDW-14.6 Plt ___
___ 05:20PM BLOOD WBC-8.9 RBC-4.24* Hgb-11.2* Hct-34.0*
MCV-80* MCH-26.4* MCHC-33.0 RDW-14.3 Plt ___
___ 05:20PM BLOOD Neuts-76.9* Lymphs-15.1* Monos-7.1
Eos-0.4 Baso-0.4
___ 05:20PM BLOOD ___ PTT-27.5 ___
___ 05:20PM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-132*
K-4.0 Cl-98 HCO3-23 AnGap-15
___ 07:15AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
___ 05:26PM BLOOD Lactate-0.8
CT PELVIS W/CONTRAST Study Date of ___ 7:50 ___
IMPRESSION:
Status post proctocolectomy with J-pouch anastomosis. No
evidence of
anastomotic leak or other complication.
Pouchogram results ___: please see brief hospital course.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dextroamphetamine 20 mg PO QD
2. QUEtiapine Fumarate 100 mg PO QHS
3. Cyclobenzaprine 5 mg PO QD:PRN back pain
4. Lorazepam 1 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Cyclobenzaprine 5 mg PO QD:PRN back pain
2. Dextroamphetamine 20 mg PO DAILY
3. QUEtiapine Fumarate 100 mg PO QHS
4. Lorazepam 1 mg PO Q8H:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea, vomiting (resolved). J pouch with continued leak, unable
to reverse ileostomy this admission.
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: ___ s/p recent proctocolectomy p/w fever // assess for
infiltrate
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 PELVIS
INDICATION: ___ year old man s/p protocolectomy w/ J pouch and diverting
ileostomy presents with fever// assess for leak or abscess.
TECHNIQUE: MDCT axial images were acquired through pelvis following
intravenous contrast administration with split bolus technique. In addition,
50 cc of water-soluble contrast was administered into the rectum. Coronal and
sagittal reformations were performed and submitted to PACS for review.
DOSE: DLP: 185.16 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
Patient is known to have a diverting ileostomy in the right lower anterior
abdominal wall without evidence of peristomal hernia or obstruction. Imaged
loops of bowel appear decompressed. Patient has a history of proctocolectomy
with J-pouch anastomosis performed recently. The rectal tube is coiled within
the remnant rectoanal canal. Water-soluble contrast administered via rectal
tube demonstrates no evidence of anastomotic leak. There is no free air or
abscess formation. Small amount of fluid along the perirectal fat is likely
postsurgical. Ureters opacified normally in the urinary bladder appears
normal.
Bones: Unremarkable.
IMPRESSION:
Status post proctocolectomy with J-pouch anastomosis. No evidence of
anastomotic leak or other complication.
Radiology Report
INDICATION: ___ year old man with robotic proctectomy J-pouch and loop
ileostomy.
TECHNIQUE: Pouchogram
COMPARISON: Examination dated ___.
FINDINGS:
After scout images were obtained, a ___ Foley catheter was inserted into
the
rectum. 75 cc of water soluble contrast was gently hand injected.
Contrast was seen filling the J-pouch and extending into the colon. No
evidence of leak was identified. Previously seen channel of extraluminal
contrast within the inferior end of the pouch no longer present on current
examination.
Post-evacuation scout image also showed no evidence of leak.
IMPRESSION:
No extraluminal contrast to suggest a leak.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, N/V
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.4
heartrate: 101.0
resprate: 20.0
o2sat: 95.0
sbp: 99.0
dbp: 56.0
level of pain: 0
level of acuity: 3.0 | ___ was admitted to the inpatient colorectal surgery
service after having fever, nausea, and an episode of vomiting.
These symptoms quickly resolved. ___ was back to his
baseline. His labs were stable and he was given intravenous
fluids. The CT scan preformed at admission was done with rectal
contrast and the read showed no leak from the Jpouch. Dr. ___
___ a repeat Pouchogram which has been preformed
approximately a week prior which showed a leak of contrast at
the inferior end. The pouchogram was repeated on ___ and
after much review with radiology and Dr. ___ continued
to be a very small amount of contrast from this area of the
pouch. It had significantly decreased from the previous study.
The ileostomy takedown was delayed given this finding as it
would not be ideal in the setting of this small leak. Our
outpatient office will contact ___ to arrange a follow up
exam and schedule surgery at the appropriate time determined by
Dr. ___. At the time of discharge, ___ was doing very
well and tolerating a regular diet and his medications without
issue. His home medications were reconciled and he was
discharged home in the care of his father. ___ mood and
behavior was appropriate throughout his hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Wellbutrin
Attending: ___.
Chief Complaint:
left breast infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F presenting with 2 weeks left breast lump. Patient was
seen by doctor at ___ who prescribed clindamycin 300 mg QID x 10
days. Patient has been on antibiotic management for the last 8
days. However, symptoms are getting worse, increasing size,
erythema and tenderness of L breast less ion. Denies fever,
chills or any other symptoms associated. Patient went to ED ___
today where an US was taken demonstrating left ___ areolar
abscess measuring 3.5 x1.3 cm at 8 o'clock, patient underwent to
needle aspiration under US, 1cc was drained , unable to drain
anymore, per patient information, due to thick fluid. Surgery
was
consulted and recommended I & D, however insurance will no cover
proceedure at ___. Patient present to ___ for further
management.
Past Medical History:
PMH: Meningitis ___ years old, depression
PSH: More than ___ MSK surgeries for meningococcal complications
including bilateral TMA
Social History:
___
Family History:
non-contributory
Physical Exam:
VS: 97.8 97.8 67 107/55 16 98% RA
NAD
RRR
CTA b/l
soft, ND/NT, + BS
left breast - erythema in the inferior outer quadrant
surrounding the areola, minimal fluctuance, no discharge
Pertinent Results:
___ 08:26PM BLOOD WBC-9.3 RBC-4.05* Hgb-13.2 Hct-38.2
MCV-95 MCH-32.6* MCHC-34.5 RDW-11.9 Plt ___
___ 01:30PM BLOOD WBC-6.8 RBC-3.88* Hgb-12.8 Hct-36.8
MCV-95 MCH-33.0* MCHC-34.8 RDW-12.0 Plt ___
___ 08:48PM BLOOD Lactate-1.0
___ US of the left breast
- subareaolar collection maximum dimension 3 cm, not liqufied,
no amendable to drainage
Medications on Admission:
Prozac 20' / Clindamycin 300 QID for the las 8 days
Discharge Medications:
1. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/headache.
Disp:*60 Tablet(s)* Refills:*2*
3. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. tramadol 50 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 7 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left breast infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Subareolar breast abscess. Please assess.
COMPARISON: Comparison is made to outside hospital ultrasound performed
___.
FINDINGS: There is a 3.4 x 1.3 x 2.3 cm relatively walled off collection in
the left breast subareolar in location with extension outside the areola seen
from 5 o'clock to 9 o'clock. Minimal surrounding hyperemia evident.
Collection has only minimally liquified content and is unlikely amenable to
aspiration.
IMPRESSION: 3.5-cm minimally liquefied collection in the left subareolar
breast extending from 5 o'clock to 9 o'clock. Not amenable to aspiration
given semisolid content.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BREAT ABCESS
Diagnosed with INFLAM DISEASE OF BREAST
temperature: 98.4
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 69.0
level of pain: 8
level of acuity: 3.0 | Patient was admitted last night after she was seen at the ___.
The repeat US was performed that did not show any fluid
collection, thus the aspiration was not performed, neither was
operative incision and drainage. Vancomycin was administered,
patient tolerated it well. Her pain was well controlled with
non-narcotic medications ibuprofen and Tylenol. She remained
afebrile with stable vital signs. Her WBC and differential were
normal. Patient is being sent home on Bactrim for 7 days. She
will follow up with Dr. ___.
Patient understood and agreed with discharge planning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
wt loss
Major Surgical or Invasive Procedure:
PEG Tube
History of Present Illness:
Mr. ___ is a ___ male with history of squamous
cell carcinoma of the right tonsil treated with definitive
radiation in ___ complicated by dysphasia, COPD, substance
abuse, hypertension, history of pneumothorax, seizure disorder,
colonic adenoma who presents for failure to thrive. He explains
that he has had difficulty eating due to his dysphagia. He was
evaluated by speech therapist and found to have moderate oral
and
mild pharyngeal dysphagia. For the oral dysphasia he requires
dentures. However, prior to that she needs some teeth
extracted.
Because of his inability to swallow, he has been eating less and
less. Also, he complains of diarrhea that has been going on for
several months. As soon as he eats, he has a bowel movement and
it seems that nothing remains in his system. He has as many
bowel movements a day as times that he eats. He denies having
blood in the stools, except perhaps some small bright red
streaks.
He also notes that he drinks multiple shots of brandy a day. He
has a history of alcohol withdrawal. Also smokes, but declines
a
nicotine patch at this time.
In the emergency department he was given 80 mEq potassium
chloride.
ROS: No headaches, occasional chest pain. Occasional shortness
of breath. No constipation. Dysuria only today after a
catheter
placement was attempted.
Past Medical History:
1. T2 N0 M0 squamous cell cancer of soft palate
treated with radical chemoradiation, completed ___ yo M w/
T2No
2. seasonal allergies
3. asthma
4. adenomatous colonic polyps
5. anemia
6. B12 deficiency
7. COPD,
8. GI bleed
9. H pylori
10 hemorrhoids
11 HTN
12 leukopenia,
13 pancreatic pseudocyst/ h/o pancreatitis,
14.EtOH, cocaine, tobacco abuse
15.PEG tube placement ___
Social History:
___
Family History:
Reports MI in father and grandmother
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress, emaciated
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, except for fine rales in left base. Breathing is
non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Then, emaciated
extremities. Onychomycosis on bilateral feet.
SKIN: No rashes or ulcerations noted. Left upper quadrant scar
from previous PEG tube.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout. Strength decreased throughout.
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:45AM BLOOD WBC-2.8* RBC-2.18* Hgb-7.2* Hct-20.6*
MCV-95 MCH-33.0* MCHC-35.0 RDW-16.7* RDWSD-57.1* Plt ___
___ 03:08PM BLOOD ___ PTT-31.6 ___
___ 05:45AM BLOOD Glucose-91 UreaN-5* Creat-0.4* Na-140
K-3.0* Cl-107 HCO3-22 AnGap-11
___ 05:45AM BLOOD ALT-15 AST-29 AlkPhos-135* TotBili-0.6
___ 03:08PM BLOOD CK-MB-2 proBNP-649*
___ 05:45AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.7
___ 05:45AM BLOOD Ferritn-629*
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
unchanged. The
pulmonary vasculature is normal. Chain sutures in the left apex
are
re-demonstrated. Lungs are clear. No pleural effusion or
pneumothorax is
seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
IMPRESSION:
1. New 4 mm right upper lobe solid lung nodule is indeterminate.
Given
history of malignancy, recommend follow-up chest CT in 3 months.
2. Superficial 3.9 lesion in the subcutaneous right inguinal
region measuring
intermediate density. This may represent l a soft tissue mass.
Ultrasound is
recommended for further evaluation
3. Increased ectasia and dilatation of the main pancreatic duct
up to 8 mm,
previously 6 mm in ___.
FINDINGS:
1. Successful placement of a 18 ___ MIC gastrostomy tube
utilizing a
balloon push technique.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrostomy tube.
___ 05:50AM BLOOD WBC-4.7 RBC-2.81* Hgb-8.6* Hct-24.0*
MCV-85 MCH-30.6 MCHC-35.8 RDW-17.2* RDWSD-53.5* Plt ___
___ 07:10AM BLOOD ___ PTT-45.1* ___
___ 05:50AM BLOOD Glucose-86 UreaN-6 Creat-0.3* Na-132*
K-4.1 Cl-96 HCO3-27 AnGap-9*
___ 06:31AM BLOOD ALT-17 AST-42* AlkPhos-122 TotBili-0.4
___ 03:08PM BLOOD CK-MB-2 proBNP-649*
___ 05:50AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.0
___ 05:45AM BLOOD Ferritn-629*
___ 06:26AM BLOOD HIV Ab-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acamprosate 666 mg PO TID
2. Albuterol 2 mg PO Q6H:PRN shortness of breath
3. amLODIPine 5 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN heartbrun
3. Creon 12 3 CAP PO TID W/MEALS
4. Multivitamins W/minerals Chewable 1 TAB PO DAILY
5. Nicotine Patch 14 mg TD DAILY
6. Ondansetron ODT 4 mg PO Q8H:PRN nausea
7. Phosphorus 500 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Thiamine 100 mg PO DAILY
11. TraMADol 50 mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp
#*12 Tablet Refills:*0
12. Acamprosate 666 mg PO TID
13. Albuterol 2 mg PO Q6H:PRN shortness of breath
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe malnutrition
Anemia
Alcohol use disorder
Chronic pancreatitis and pancreatic insufficiency
Dysphagia
Leukopenia/thrombocytopenia
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 weakness, FTT hx of SCC throat// Pneumonia,
lesions or masses?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___ and chest CT ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are unchanged. The
pulmonary vasculature is normal. Chain sutures in the left apex are
re-demonstrated. 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 TORSO WITH CONTRAST
INDICATION: ___ year old man with wt loss, h/o alcohol and previous ___ of
throat s/p treatment// eval for underlying malignancy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the torso 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 15.0 s, 0.2 cm; CTDIvol = 200.6 mGy (Body) DLP =
40.1 mGy-cm.
3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 338.4
mGy-cm.
Total DLP (Body) = 380 mGy-cm.; Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 15.0 s, 0.2 cm; CTDIvol = 200.6 mGy (Body) DLP =
40.1 mGy-cm.
3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 338.4
mGy-cm.
Total DLP (Body) = 380 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: MRCP from ___. CTA chest from ___.
FINDINGS:
CHEST:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. Coronary artery and aortic
annular calcifications are mild. The thoracic aorta is normal in caliber.
Trace pericardial fluid is within physiologic limits.
PLEURA: There are trace left and small right dependent nonhemorrhagic pleural
effusions. No pneumothorax.
LUNG:
1. PARENCHYMA: Mild upper lobe predominant centrilobular and paraseptal
emphysematous changes are again noted. Re-demonstration of mild biapical
scarring and suture material at the left lung apex. A 4 mm right upper lobe
solid nodule is new (5:134). An 8 mm right perifissural nodule is unchanged
(5:161). Mild dependent atelectasis is noted in the bilateral lung bases,
right greater than left.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal limits.
Evaluation of the pulmonary arterial vasculature to the segmental level
demonstrates no evidence for pulmonary embolism.
ABDOMEN:
HEPATOBILIARY: There is diffuse hepatic steatosis. There is no evidence of
focal lesions. Area of relative ___ adjacent to falciform
ligament (4:68) likely represents a perfusion anomaly. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits. The portal and hepatic veins are patent. There is moderate
volume ascites.
PANCREAS: The pancreas is atrophic and contains coarse calcifications in the
head, compatible with chronic pancreatitis. Irregular ectasia and dilatation
of the main pancreatic duct is progressed, measuring up to 8 mm in diameter
(4:67). Previously no 1.3 cm pancreatic head cyst is not well seen on the
current study.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral subcentimeter hypoattenuating lesions are too small to characterize.
No focal mass lesions are seen. There is no hydronephrosis or perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the colon is noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
moderate volume free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the lumbosacral spine, most
notable at L4-5. Sclerosis of S5 is unchanged from prior PET CT from ___.
SOFT TISSUES: There is a superficial 3.9 x 1.7 x 2.4 cm lesion in the
subcutaneous right inguinal region measuring intermediate density. The
abdominal and pelvic walls are otherwise within normal limits.
IMPRESSION:
1. New 4 mm right upper lobe solid lung nodule is indeterminate. Given
history of malignancy, recommend follow-up chest CT in 3 months.
2. Superficial 3.9 lesion in the subcutaneous right inguinal region measuring
intermediate density. This may represent l a soft tissue mass. Ultrasound is
recommended for further evaluation
3. Increased ectasia and dilatation of the main pancreatic duct up to 8 mm,
previously 6 mm in ___.
RECOMMENDATION(S): Ultrasound examination of the right inguinal region and CT
chest in 3 months
Radiology Report
EXAMINATION: CT TORSO WITH CONTRAST
INDICATION: ___ year old man with wt loss, h/o alcohol and previous ___ of
throat s/p treatment// eval for underlying malignancy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the torso 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 15.0 s, 0.2 cm; CTDIvol = 200.6 mGy (Body) DLP =
40.1 mGy-cm.
3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 338.4
mGy-cm.
Total DLP (Body) = 380 mGy-cm.; Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 15.0 s, 0.2 cm; CTDIvol = 200.6 mGy (Body) DLP =
40.1 mGy-cm.
3) Spiral Acquisition 9.9 s, 64.4 cm; CTDIvol = 5.3 mGy (Body) DLP = 338.4
mGy-cm.
Total DLP (Body) = 380 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: MRCP from ___. CTA chest from ___.
FINDINGS:
CHEST:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
There is no supraclavicular or axillary lymphadenopathy. The esophagus is
unremarkable.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. Coronary artery and aortic
annular calcifications are mild. The thoracic aorta is normal in caliber.
Trace pericardial fluid is within physiologic limits.
PLEURA: There are trace left and small right dependent nonhemorrhagic pleural
effusions. No pneumothorax.
LUNG:
1. PARENCHYMA: Mild upper lobe predominant centrilobular and paraseptal
emphysematous changes are again noted. Re-demonstration of mild biapical
scarring and suture material at the left lung apex. A 4 mm right upper lobe
solid nodule is new (5:134). An 8 mm right perifissural nodule is unchanged
(5:161). Mild dependent atelectasis is noted in the bilateral lung bases,
right greater than left.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal limits.
Evaluation of the pulmonary arterial vasculature to the segmental level
demonstrates no evidence for pulmonary embolism.
ABDOMEN:
HEPATOBILIARY: There is diffuse hepatic steatosis. There is no evidence of
focal lesions. Area of relative ___ adjacent to falciform
ligament (4:68) likely represents a perfusion anomaly. There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits. The portal and hepatic veins are patent. There is moderate
volume ascites.
PANCREAS: The pancreas is atrophic and contains coarse calcifications in the
head, compatible with chronic pancreatitis. Irregular ectasia and dilatation
of the main pancreatic duct is progressed, measuring up to 8 mm in diameter
(4:67). Previously no 1.3 cm pancreatic head cyst is not well seen on the
current study.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Bilateral subcentimeter hypoattenuating lesions are too small to characterize.
No focal mass lesions are seen. There is no hydronephrosis or perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the colon is noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
moderate volume free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There are multilevel degenerative changes of the lumbosacral spine, most
notable at L4-5. Sclerosis of S5 is unchanged from prior PET CT from ___.
SOFT TISSUES: There is a superficial 3.9 x 1.7 x 2.4 cm lesion in the
subcutaneous right inguinal region measuring intermediate density. The
abdominal and pelvic walls are otherwise within normal limits.
IMPRESSION:
1. New 4 mm right upper lobe solid lung nodule is indeterminate. Given
history of malignancy, recommend follow-up chest CT in 3 months.
2. Superficial 3.9 lesion in the subcutaneous right inguinal region measuring
intermediate density. This may represent l a soft tissue mass. Ultrasound is
recommended for further evaluation
3. Increased ectasia and dilatation of the main pancreatic duct up to 8 mm,
previously 6 mm in ___.
RECOMMENDATION(S): Ultrasound examination of the right inguinal region and CT
chest in 3 months
Radiology Report
INDICATION: ___ year old man with ng placed// tube placement.
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest dated ___
IMPRESSION:
The tip of an enteric tube projects over the stomach.
The lungs appear hyperinflated. There are new ill-defined opacities at the
right lung base which could reflect atelectasis or aspiration/pneumonitis. A
small right pleural effusion is also present. There is no pneumothorax or left
lung consolidation. The size the cardiomediastinal silhouette is within
normal limits.
Radiology Report
INDICATION: ___ year old man with hx of g tube in context of oropharyngeal
cancer. removed ___ yrs ago. admitted with severe failure to thrive (difficulty
swallowing). needs new G tube.// placement of g tube
COMPARISON: CT abdomen pelvis ___
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: 50mcg of fentanyl. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 30 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.6 minutes, 4 mGy
PROCEDURE: 1. Placement of a MIC gastrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After tract dilatation using an 8 mm balloon, a MIC gastrostomy catheter was
advanced over the wire into position. The catheter was secured by instilling 7
ml of dilute contrast into the balloon in the stomach after confirming the
position of the catheter with a contrast injection. The catheter was then
flushed, capped and secured to the skin. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a 18 ___ MIC gastrostomy tube utilizing a
balloon push technique.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrostomy tube.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old man with soft tissue density noted on CT abd over R
groin/suprapubic area of unclear significance// evaluate soft tissue density
for further characterization
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right lower quadrant and inguinal region.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right lower quadrant and inguinal region. Normal vascular structures are
identified as well as normal sonographic appearance of bowel. Right inguinal
mass better visualized on CT may represent an inguinal hernia that is not
appreciated on today's study. There is tiny volume ascites.
IMPRESSION:
Tiny amount of ascites as seen on prior CT. The suspected right inguinal mass
as seen on the prior CT is not visualized on sonography, and may have
represented ascites tracking into an inguinal hernia.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: ___ year old man with malnutrition s/p PEG Tube placement ___ and
? difficulty with tube feeds// assess PEG tube for placement
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 352 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: Bilateral pleural effusions are visualized, large on the right
and small on the left with associated compressive atelectasis. There is a
small pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous hypoattenuation throughout
compatible with hepatic steatosis. There is no evidence of focal lesions
within the limitations of an unenhanced scan. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is
unremarkable. There is small volume ascites.
PANCREAS: The pancreas is atrophic and re-demonstrates coarse calcifications
compatible with findings of chronic pancreatitis. Main pancreatic duct is
dilated measuring up to 6 mm, unchanged from prior.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The patient is status post percutaneous gastrostomy
placement with expected and normal postprocedural changes including small
volume pneumoperitoneum. Small bowel loops demonstrate normal caliber and
wall thickness throughout. Residual enteric contrast is visualized in the
colon to the level of the rectum. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding. The appendix is
not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Diffuse body wall edema is visualized throughout.
IMPRESSION:
1. Status post percutaneous gastrostomy tube placement which is seated
appropriately within the anterior fundal wall with expected postprocedural
changes including small volume pneumoperitoneum.
2. Bilateral pleural effusions, large on the right, and small on the right.
Diffuse body wall edema. Small pericardial effusion. Small volume ascites.
3. Chronic findings including unchanged pancreatic ductal dilatation and
hepatic steatosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia, Failure to thrive
Diagnosed with Dehydration, Adult failure to thrive, Weakness
temperature: 97.1
heartrate: 66.0
resprate: 18.0
o2sat: 94.0
sbp: 102.0
dbp: 77.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ male with the past medical history
and findings noted above who presented with failure to thrive. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F w/ PMH transverse colon mass, anemia,
CHF
who presents with worsening confusion and difficulty using her
right side over the past 2 weeks with CT scan concerning for
brain metastasis.
She presented at ___ this AM after ___ at a nursing
facility noted R sided weakness and facial droop. While at
___ her evaluation was notable for confusion, but no other
focal deficits. Of note, she also reportedly had a witnessed
fall
on ___ without headstrike when she was unable to "lift her
right
foot up". Thus she had a head CT at ___ that showed showed
left posterior parietal moderate sized vasogenic edema and mild
compression of the left lateral ventricle, suggesting an
underlying intra-axial mass. She received decadron and tetanus.
She was then sent to ___ for neurosurgery evaluation.
Per her daughter, she has been more confused over 2 weeks, not
remembering people's names, recent events. At baseline, she is
high-functioning, able to recall recent political events. She
was
recently admitted to ___ in ___ for anemia and
received blood transfusions and was diuresed before being sent
to
rehab. That's when her daughter noticed the confusion and that
her mother had some difficulty using her R arm and leg. She says
that her mom would veer to the R when she used her walker,
running into people and walls.
Of note, per her family, her health has been worsening overall
since ___. At that time, she was seen by her PCP for
___ edema and incidentally found to be anemic. Shortly thereafter
she had a fall in her home and was found 2 days later by her
daughter. She had an extensive workup at that time that
demonstrated a large transverse colon mass c/w schwanoma. Per
the
family, around this time she also started following with a
hematologist who said she "had a lot of protein in her blood"
and
maybe cancer. They said she had a number of bone scans that
showed her bones were "affected by the blood proteins". Since
then she has been getting monthly blood transfusions.
In the ED, vitals were: T 98.8, HR 84, BP 140/80, RR 16 SaO2 96%
on RA
Exam Notable for:
Neurologic: Awake, alert, moves all extremities. Speech fluent.
Weakness of right leg compared to left. Pt has equal upper
extremity strength but some difficulty following commands with
right arm.
Labs notable for:
Hgb: 9.2
Cr: 1.2
Alk Phos: 177, T bili: 1.9, lipase: 70
She was given Keppra 500mg x 1.
She was evaluated by neurosurgery, who reviewed the CT from
___ and saw multiple lesions.
On arrival to the floor, patient says that she is frustrated
that
she is causing so much stress on her family. She denies pain,
shortness of breath, chest discomfort. Endorses increased
urinary
frequency and fatigue since her recent hospital stay.
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Essential Tremor
CHF
NSTEMI ___ iso severe anemia and urosepsis
Microcytic Anemia
Transverse Colon Mass
Social History:
___
Family History:
Father- prostate cancer
Sister- rheumatic heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:24 HR Data (last updated ___ @ ___
Temp: 98.3 (Tm 98.3), BP: 134/77, HR: 79, RR: 18, O2 sat:
94%, O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 2+ pitting edema to the knees bilaterally. DP
pulses
palpable.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AxO to self and season. CNII-XII intact, except for
decreased hearing in the L ear. ___ strength in the RUE and RLE.
___ strength with dorsiflexion of R foot. Sensation intact. LUE
and LLE ___ strength. Gait not assessed.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 920)
Temp: 98.0 (Tm 98.5), BP: 160/82 (114-160/65-82), HR: 96
(84-96), RR: 17 (___), O2 sat: 92% (92-94), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
RESPIRATORY: no increased work of breathing
NEUROLOGIC: AxO to self and a hospital, does not state city or
year.
Pertinent Results:
ADMISSION LABS
___ 01:47PM BLOOD WBC-8.0 RBC-3.16* Hgb-9.2* Hct-31.6*
MCV-100* MCH-29.1 MCHC-29.1* RDW-25.2* RDWSD-91.8* Plt ___
___ 01:47PM BLOOD Neuts-70.8 ___ Monos-5.0 Eos-2.9
Baso-0.7 Im ___ AbsNeut-5.68 AbsLymp-1.60 AbsMono-0.40
AbsEos-0.23 AbsBaso-0.06
___ 01:47PM BLOOD ___ PTT-30.6 ___
___ 01:47PM BLOOD Glucose-106* UreaN-36* Creat-1.2* Na-142
K-3.8 Cl-109* HCO3-18* AnGap-15
___ 06:46AM BLOOD Albumin-3.6 Calcium-9.3 Phos-4.5 Mg-2.2
Iron-51 Cholest-217*
___ 01:47PM BLOOD ALT-20 AST-33 AlkPhos-177* TotBili-1.9*
___ 06:46AM BLOOD calTIBC-395 VitB12-661 Ferritn-62 TRF-304
___ 06:46AM BLOOD %HbA1c-4.8 eAG-91
___ 06:46AM BLOOD Triglyc-34 HDL-91 CHOL/HD-2.4 LDLcalc-119
OTHER RELEVANT LABS
___ 04:51AM BLOOD PEP-ABNORMAL B FreeKap-20.3*
FreeLam-1486* Fr K/L-0.01* IgG-603* IgA-37* IgM-5*
IFE-MONOCLONAL
RELEVANT STUDIES
___ MRI BRAIN W AND WO CONTRAST
FINDINGS:
There is a confluent area of DWI hyperintensity centered in the
left
parieto-occipital region with extension anteriorly into the left
frontal lobe.
This area demonstrates corresponding ADC hypointensity and also
areas of ADC
T2 shine through effect, increased FLAIR signal, most consistent
with a late
subacute infarcts in a watershed distribution, please correlate.
There are also linear, gyriform T1 hyperintensities in the left
parietal lobe
(series 3, image 15 and 16, consistent with cortical laminar
necrosis.
There is mild associated edema within the infarct region
resulting in partial
effacement of the left occipital horn, which is uncommon in
acute/subacute
ischemic changes, therefore close follow-up is recommended, and
if clinically
warranted an MRI of the head with and without contrast can be
obtained in ___
weeks or as clinically warranted.
There are additional scattered T2/FLAIR hyperintensities in the
cerebral
hemispheres bilaterally and in the pons, a nonspecific finding
and likely
related to chronic small vessel ischemic changes. There is no
evidence of
abnormal enhancement after contrast administration.
There is mild generalized parenchymal volume loss, most likely
age related.
Prominence of the ventricular system and extra-axial CSF spaces
is consistent
with the previously mentioned parenchymal volume loss.
Major vascular flow voids appear preserved. Major dural venous
sinuses are
patent.
The paranasal sinuses appear clear. There is minimal
opacification of the
inferior bilateral mastoid air cells. The orbits appear
unremarkable.
IMPRESSION:
1. Late subacute infarct involving the left parieto-occipital
region with
extension in to the left frontal lobe and evidence of cortical
laminar
necrosis, in a watershed distribution, please correlate.
2. Scattered white matter changes in the cerebral hemispheres
bilaterally and
in the pons likely reflect sequela of chronic small vessel
ischemic changes.
RECOMMENDATION(S): There is mild associated edema within the
infarcted region
resulting in partial effacement of the left occipital horn,
close follow-up is
recommended, if clinically warranted MRI of the head with and
without contrast
can be obtained in ___ weeks to demonstrate evolution and
further changes.
CTA HEAD AND NECK ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Redemonstration of hypodensity in the left parieto-occipital
region with
extension into the left frontal lobe, consistent with the
patient's known
subacute infarction previously identified on the MRI.
Areas of hyperdensity along the left parietal gyri (for example
series 2,
image 26) are again seen and correspond to the previously
identified cortical
laminar necrosis.
Additional scattered white matter lesions in the cerebral
hemispheres
bilaterally are nonspecific but suggestive of chronic small
vessel ischemic
changes.
Calcification of the bilateral basal ganglia are unchanged.
Again noted is mild generalized parenchymal volume loss which is
most likely
age related. Mild prominence of the ventricular system and
extra-axial CSF
spaces is stable and consistent with the previously mentioned
parenchymal
volume loss.
The visualized portion of the paranasal sinuses, mastoid air
cells,and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation.
The dural venous sinuses are patent.
CTA NECK:
The carotidandvertebral arteries and their major branches appear
normal with
no evidence of stenosis or occlusion. There is no evidence of
significant
internal carotid stenosis by NASCET criteria.
OTHER:
There is gravity dependent atelectasis. No suspicious pulmonary
nodules.
There are subcentimeter hypodense nodules in the bilateral
thyroid lobes, no
follow-up is indicated according to current guidelines. There
is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Redemonstration of the patient's known subacute infarction in
the left
parieto-occipital region with extension into the left frontal
lobe and
evidence of areas of cortical laminar necrosis.
2. Additional scattered periventricular hypodensities are
nonspecific but
suggestive of chronic small vessel ischemic changes.
3. Patent intracranial and cervical vasculature without evidence
of stenosis,
occlusion, dissection or aneurysm formation greater than 3 mm.
DISCHARGE LABS
___ 05:08AM BLOOD WBC-9.3 RBC-3.20* Hgb-9.5* Hct-30.9*
MCV-97 MCH-29.7 MCHC-30.7* RDW-25.4* RDWSD-87.5* Plt ___
___ 05:08AM BLOOD Glucose-95 UreaN-41* Creat-1.3* Na-143
K-4.2 Cl-108 HCO3-22 AnGap-13
___ 05:08AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.3
___ 05:08AM BLOOD ALT-20 AST-22 AlkPhos-173* TotBili-1.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Cranberry Concentrate (cranberry conc-ascorbic
acid;<br>cranberry extract) 400 mg oral DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
8. nystatin 1 app topical TID
9. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*1
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a
day Refills:*1
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Furosemide 40 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Subacute stroke versus intracranial mass with vasogenic edema
Anemia
Right-sided weakness
Chronic kidney disease
SECONDARY DIAGNOSES:
Congestive heart failure
Gastrointestinal schwannoma
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: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with brain mass on CT// Please perform MRI
brain w/ and w/o contrast for metastatic disease.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT of the cervical spine from ___, outside study.
FINDINGS:
There is a confluent area of DWI hyperintensity centered in the left
parieto-occipital region with extension anteriorly into the left frontal lobe.
This area demonstrates corresponding ADC hypointensity and also areas of ADC
T2 shine through effect, increased FLAIR signal, most consistent with a late
subacute infarcts in a watershed distribution, please correlate.
There are also linear, gyriform T1 hyperintensities in the left parietal lobe
(series 3, image 15 and 16, consistent with cortical laminar necrosis.
There is mild associated edema within the infarct region resulting in partial
effacement of the left occipital horn, which is uncommon in acute/subacute
ischemic changes, therefore close follow-up is recommended, and if clinically
warranted an MRI of the head with and without contrast can be obtained in ___
weeks or as clinically warranted.
There are additional scattered T2/FLAIR hyperintensities in the cerebral
hemispheres bilaterally and in the pons, a nonspecific finding and likely
related to chronic small vessel ischemic changes. There is no evidence of
abnormal enhancement after contrast administration.
There is mild generalized parenchymal volume loss, most likely age related.
Prominence of the ventricular system and extra-axial CSF spaces is consistent
with the previously mentioned parenchymal volume loss.
Major vascular flow voids appear preserved. Major dural venous sinuses are
patent.
The paranasal sinuses appear clear. There is minimal opacification of the
inferior bilateral mastoid air cells. The orbits appear unremarkable.
IMPRESSION:
1. Late subacute infarct involving the left parieto-occipital region with
extension in to the left frontal lobe and evidence of cortical laminar
necrosis, in a watershed distribution, please correlate.
2. Scattered white matter changes in the cerebral hemispheres bilaterally and
in the pons likely reflect sequela of chronic small vessel ischemic changes.
RECOMMENDATION(S): There is mild associated edema within the infarcted region
resulting in partial effacement of the left occipital horn, close follow-up is
recommended, if clinically warranted MRI of the head with and without contrast
can be obtained in ___ weeks to demonstrate evolution and further changes.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: Ms. ___ is a ___ yo F w/ PMH transverse colon
Schwannoma,anemia, CHF who presents with worsening confusion and
difficultyusing her right side over the past 2 weeks with CT scan atBrockton
initially concerning for metastasis causing mass effect,now transferred here
with MRI likely indicating stroke, but also concern for possible malignancy.//
evaluate for vascular disease, stroke
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 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 5.1 s, 39.8 cm; CTDIvol = 13.3 mGy (Body) DLP = 529.2
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 32.7 mGy (Body) DLP =
16.3 mGy-cm.
Total DLP (Body) = 547 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: MRI of the head from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Redemonstration of hypodensity in the left parieto-occipital region with
extension into the left frontal lobe, consistent with the patient's known
subacute infarction previously identified on the MRI.
Areas of hyperdensity along the left parietal gyri (for example series 2,
image 26) are again seen and correspond to the previously identified cortical
laminar necrosis.
Additional scattered white matter lesions in the cerebral hemispheres
bilaterally are nonspecific but suggestive of chronic small vessel ischemic
changes.
Calcification of the bilateral basal ganglia are unchanged.
Again noted is mild generalized parenchymal volume loss which is most likely
age related. Mild prominence of the ventricular system and extra-axial CSF
spaces is stable and consistent with the previously mentioned parenchymal
volume loss.
The visualized portion of the paranasal sinuses, mastoid air cells,and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation.
The dural venous sinuses are patent.
CTA NECK:
The carotidandvertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of significant
internal carotid stenosis by NASCET criteria.
OTHER:
There is gravity dependent atelectasis. No suspicious pulmonary nodules.
There are subcentimeter hypodense nodules in the bilateral thyroid lobes, no
follow-up is indicated according to current guidelines. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Redemonstration of the patient's known subacute infarction in the left
parieto-occipital region with extension into the left frontal lobe and
evidence of areas of cortical laminar necrosis.
2. Additional scattered periventricular hypodensities are nonspecific but
suggestive of chronic small vessel ischemic changes.
3. Patent intracranial and cervical vasculature without evidence of stenosis,
occlusion, dissection or aneurysm formation greater than 3 mm.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Other specified disorders of brain
temperature: 98.8
heartrate: 84.0
resprate: 16.0
o2sat: 96.0
sbp: 140.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT:
====================
___ female with a history of transverse colon mass with
tissue diagnosis of schwannoma, anemia who presented with 2
weeks of worsening confusion and right-sided weakness to
___, transferred to ___ for neurosurgical
evaluation once CT showed left-sided vasogenic edema concerning
for malignancy. Here, MRI of the brain showed findings that may
have been compatible with either stroke, underlying malignancy,
or both. Based on the patient's goals of care, it was determined
that even with the least invasive treatment and the best
prognosis she likely would not want to undergo evaluation.
Patient was made DNR/DNI and was discharged to hospice. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
___ Complaint:
Dyspnea, positive Biopsy
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ with newly dx high grade DLBCL (dx ___ by bx) who presented
with progressively worsening SOB. He reports having worsening
SOB over the last month with associated 10 pound weight loss and
decreased appetite, fever to 100.7. He presented initially with
shortness of breath to his PCP who sent for a CXR which had
findings of potential thoracic masses, so he had a CT chest
which showed the extent of the masses and multiple enlarged
lymph nodes. He then had a CT PET scan which showed extensive
disease. Around the same time he had recurrence of an anterior
chest wall subcutaneous mass that had been removed previously
and thought of to be a lipoma. He subsequently saw Dr. ___ in
CT surgery who did a biopsy of the anterior chest wall mass
which demonstrated the aforementioned DLBCL.
A chest on CT ___ noted bilat large soft tissue masses
upper lobes consistent with bilat hilar adenopathy left > right.
multiple ill defined scattered opacities measuring up to 1 cm,
upper lobe predominant. The patient had a PET-CT with large
mediastinal masses and innumerable FDG avid lymph nodes in neck,
chest, and abdomen. Ultrasound-guided core needle biopsy of left
anterior chest wall soft tissue mass on ___ returned with
DLBCL, likely germinal-center type, with high proliferation
index of 80% with extensive mediastinal, periceliac, and
periportal adenopathy and small pericardial LNs as well. He
presents for evaluation of the masses and initiation of
chemotherapy.
Of note, the patient was admitted ___ in ___ while visiting
family for the holidays for jaundice, found to have biliary
ductal obstruction, and underwent stent placement. He was told
that the stent was temporary and could be removed as soon as
this week but his PCP at ___ suggested that he wait to
establish care here first in order to have one of our
___ physicians discuss stent management.
In the ED, his initial vitals were 97.9 116 128/94 18 97% RA
ECG showed sinus tachycardia
CT scan of torso showed multiple masses and lymphadenopathy,
full report below.
Labs significant for an LDH elevated to 587, H/H ___,
otherwise unremarkable.
On the floor, the patient reports feeling dyspneic beyond his
baseline anemia, requiring him to rest after only walking about
100 feet. He also reports ___ intermittent lower chest/back
pain that has been consisitent for approximately 3 weeks. He
also reports recent nightsweats,, swollen gland on L side of
neck, and 10 lb weight loss but denies abdominal pain, changes
in bowels.
Past Medical History:
HTN
HLD
Asthma
GERD
eczema
myclonus
sleep apnea
Social History:
___
Family History:
lung cancer - mother, father, aunt, grandmother
Physical ___:
Admission:
VITALS - 98.4 109 124/76 24 92%RA
General: NAD, lying comfortably in bed looking slightly anxious
HEENT: MMM, L sided submandibular LN enlarged but nontender,
fixed
CV: RRR no M/R/G
Lungs: CTAB no w/r/r
Abdomen: Nontender, nondistended, normal BS
Ext: no pedal edema. warm, well perfuised
Neuro: CN ___ grossly intact. Strength ___ ___ b/l, gait
deferred
Discharge:
Vitals:98.6 98.8 91-105 140s/80s 18 95% RA
General: NAD, lying comfortably in bed
HEENT: MMM, L sided submandibular LN enlarged but nontender,
fixed
CV: RRR no M/R/G
Lungs: CTAB no wheezing.
Abdomen: Nontender, nondistended, normal BS
Ext: no pedal edema. warm, well perfused
Neuro: CN ___ grossly intact. Strength ___ ___ b/l, gait
deferred. B/l hands with tremor but not obvious asterixis
Pertinent Results:
Admission:
___ 06:50PM GLUCOSE-154* UREA N-10 CREAT-0.8 SODIUM-134
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14
___ 06:50PM ALT(SGPT)-45* AST(SGOT)-33 LD(LDH)-476* ALK
PHOS-93 TOT BILI-0.5
___ 06:50PM CALCIUM-10.4* PHOSPHATE-4.1 MAGNESIUM-2.1
URIC ACID-6.5
___ 06:50PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE
___ 06:50PM HIV Ab-Negative
___ 06:50PM HCV Ab-NEGATIVE
___ 06:50PM WBC-7.0 HGB-10.2* HCT-31.6*
___ 06:50PM PLT COUNT-596*
___ 06:50PM ___ PTT-27.8 ___
___ 06:50PM QUAN G6PD-9.2
___ 06:50PM RET AUT-2.4* ABS RET-0.08
___ 11:20AM URINE HOURS-RANDOM
___ 11:20AM URINE HOURS-RANDOM
___ 11:20AM URINE UHOLD-HOLD
___ 11:20AM URINE GR HOLD-HOLD
___ 11:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:20AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:29AM LACTATE-1.6
___ 09:20AM GLUCOSE-101* UREA N-11 CREAT-0.7 SODIUM-135
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
___ 09:20AM estGFR-Using this
___ 09:20AM LD(LDH)-587*
___ 09:20AM cTropnT-<0.01
___ 09:20AM CALCIUM-10.0 PHOSPHATE-4.5 URIC ACID-6.3
___ 09:20AM proBNP-27
___ 09:20AM CALCIUM-10.0 PHOSPHATE-4.5 URIC ACID-6.3
___ 09:20AM WBC-7.5 RBC-3.51* HGB-10.0* HCT-30.9* MCV-88
MCH-28.5 MCHC-32.4 RDW-13.2 RDWSD-42.1
___ 09:20AM NEUTS-69.9 LYMPHS-10.9* MONOS-12.7 EOS-4.8
BASOS-0.8 IM ___ AbsNeut-5.23 AbsLymp-0.82* AbsMono-0.95*
AbsEos-0.36 AbsBaso-0.06
___ 09:20AM PLT COUNT-604*
___ 09:20AM ___ PTT-29.6 ___
Discharge:
___ 12:00AM BLOOD WBC-3.7* RBC-2.99* Hgb-8.7* Hct-25.6*
MCV-86 MCH-29.1 MCHC-34.0 RDW-12.5 RDWSD-39.0 Plt ___
___ 12:00AM BLOOD Neuts-98* Bands-0 Lymphs-2* Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-3.63 AbsLymp-0.07*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD ___ PTT-23.3* ___
___ 12:00AM BLOOD Glucose-131* UreaN-10 Creat-0.6 Na-134
K-3.0* Cl-97 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-102* AST-33 LD(LDH)-325* AlkPhos-76
TotBili-0.6
___ 12:00AM BLOOD CK(CPK)-36*
___ 12:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 UricAcd-3.7
Imaging:
___ Imaging LIVER OR GALLBLADDER US
1. Hepatic steatosis.
2. Expected pneumobilia without intrahepatic duct dilation.
The CBD could not be visualized due to bowel gas.
___ Imaging DX CHEST PORTABLE PICC
Right PICC terminates in the lower superior vena cava adjacent
to the junction with the right atrium.
Widespread abnormalities in keeping with history of lymphoma,
which have been more fully characterized by concurrent chest
CTA, dictated separately.
___ Imaging CTA CHEST W&W/O C&RECON
1. Supraclavicular, mediastinal, and hilar conglomerate lymph
node masses
consistent with recently diagnosed diffuse B-cell lymphoma,
overall size has mildly decreased compared to prior PET-CT from
___.
2. Anterior mediastinal lymph node masses surrounds the
ascending aorta out without vascular invasion.
3. Hilar lymph node masses causes narrowing of the bilateral
upper lobe
pulmonary arteries and narrowing of the segmental bronchi, most
pronounced in the left upper lobe.
4. No evidence of pulmonary embolism or aortic abnormality.
5. Multiple pulmonary nodules, some new, some increased, and
some decreased
compared to ___ given short-term interval change,
findings are likely infectious.
6. 12 mm hypodense thyroid nodule if clinically indicated a non
emergent
thyroid ultrasound can be obtained.
___ Cardiovascular ECG: Sinus tachycardia. Delayed R wave
transition. Cannot exclude an anterior myocardial infarction,
age undetermined. No previous tracing available for
comparison.
___ Imaging US THORACENTESIS/PLEURA: Uneventful
ultrasound-guided core needle biopsy of the left anterior chest
wall soft tissue mass.
___ Cytogenetics Tissue: TUMOR
-NEGATIVE for IGH/BCL2 and REARRANGEMENT of BCL6 and MYC,
POSITIVE for GAIN
of MYC.
___ Cytogenetics Tissue: TUMOR
-Chromosome analysis was not possible because the cultures set
up from this chest wall mass core biopsy did not produce mitotic
cells. However, FISH was positive
for interphase cells with three intact MYC gene signals (see
below).
___ Cytology TOUCH PREP OF CORE
-POSITIVE FOR MALIGNANT CELLS.
___ Pathology Tissue: SOFT TISSUE, CORE BIOPSY FOR TUMOR
-Involvement by a HIGH GRADE B-CELL LYMPHOMA WITH FEATURES
INTERMEDIATE
BETWEEN A DIFFUSE LARGE B CELL LYMPHOMA AND BURKITT LYMPHOMA,
___ Pathology Tissue: immunophenotyping-chest:
Immunophenotypic findings consistent with involvement by a
kappa-restricted B cell lymphoma. Correlation with clinical,
morphologic (see separate pathology report ___), and
cytogenetic findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
___ Cardiovascular ECHO: The left atrium and right atrium
are normal in cavity size. No atrial septal defect is seen by 2D
or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF=70%). 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 appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Sinus tachycardia. Normal biventricular chamber size
and systolic function. No pathologic valvular flow.
___ Imaging MR HEAD W & W/O CONTRAST: 1. No acute
intracranial abnormality. No intracranial metastasis from
patient's recently diagnosed lung cancer.
2. Abnormal enlargement of the visualized Waldeyer's ring and of
paravertebral lymph nodes, compatible with metastatic disease.
___ Imaging FDG TUMOR IMAGING (PET):
1. Multiple large soft tissue masses are noted which obliterate
epicardial and pericardial fat planes and extend to the hila
bilaterally,
concerning for large conglomerations of lymph nodes. These
findings would be more consistent with lymphoma versus atypical
lung cancer.
2. Innumerable enlarged FDG avid lymph nodes are noted
throughout the neck, chest and abdomen as detailed above.
3. FDG avidity and wall thickening within the greater curvature
of the stomach is concerning for metastatic disease.
4. Innumerable bilateral ground-glass and solid pulmonary
opacities are FDG avid and worrisome for malignancy.
5. A large FDG avid lesion in the region of the head of the
pancreas is poorly characterized without intravenous contrast.
Micro:
___ IMMUNOLOGY HCV VIRAL LOAD: HCV-RNA NOT
DETECTED.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
___ IMMUNOLOGY HBV Viral Load: HBV Viral Load
(Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ BLOOD CULTURE Blood Culture: Blood Culture,
Routine (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture: Blood Culture,
Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
2. Omeprazole 20 mg PO DAILY
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. Nortriptyline 150 mg PO QHS
5. irbesartan 150 mg oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Cetirizine 10 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Filgrastim 300 mcg SC Q24H
RX *filgrastim [Neupogen] 300 mcg/0.5 mL ___aily Disp
#*14 Syringe Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Cetirizine 10 mg PO DAILY
4. Nortriptyline 150 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Amlodipine 5 mg PO HS
RX *amlodipine 5 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
8. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth q8hr Disp #*42 Tablet
Refills:*0
9. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diffuse Large B cell lymphoma
Secondary: HTN, asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ man with newly diagnosed high-grade b-cell lymphoma
with progressive shortness of breath.
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: Total DLP (Body) = 266 mGy-cm.
COMPARISON: PET-CT ___, reference chest CT ___.
FINDINGS:
CTA: The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary trunk is not dilated.
Bilateral hilar lesions causes narrowing of the bilateral upper lobe pulmonary
arteries however, these vessels remain patent.
CT CHEST: There is a 12 mm hypodense right thyroid nodule (series 3, image
23). Axillary lymph nodes are mildly enlarged measuring up to 14 mm on the
left (series 3, image 101). There is extensive supraclavicular and
mediastinal lymphadenopathy. The largest lymph node conglomerate is in the
anterior mediastinum and measures 10.7 x 3.6 cm (transverse by AP), mildly
decreased compared to prior PET-CT. This mass obliterates the fat plane
between the ascending aorta, without invasion. In addition, there are
bilateral hilar masses, larger on the left measuring 3.9 x 5.1 cm (series 3,
image 91), also decreased from ___.
Heart size is normal. There is no pericardial effusion. No significant
Coronary artery calcifications.
The airways are patent to the segmental level bilaterally. Left hilar lesion
causes significant narrowing of a bilateral upper lobe segmental bronchus
without occlusion (series 3, image 108). There are multiple bilateral
ill-defined pulmonary nodules. The largest is in the left lung apex and
measures 2.0 x 1.5 cm (series 3, image 66), new from ___ (previously
2.1 x 2.0 cm). Multiple additional pulmonary nodules are present some of
which have increased and others which have decreased from ___.
Example of a lesion which has significantly decreased in size is a left medial
upper lobe lesion which measured 3.7 x 3.3 cm, now 2.6 x 1.5 cm (series 3,
image 75). There is interlobular septal thickening at the lung apices left
greater than right. Right basilar atelectasis has not largely changed
compared to prior PET-CT. Also not largely changed is left lower lobe
ground-glass opacity.
The thoracic esophagus is unremarkable. Retrocrural and retroperitoneal
adenopathy is again seen. A common bile duct stent is stably positioned.
Pneumobilia, primarily left-sided is present as expected. Views of the upper
abdomen are otherwise unremarkable. FDG avid pancreatic lesion is not imaged
on the current study.
OSSEOUS STRUCTURES: Soft tissue lesions demonstrated to be FDG avid extending
involving the right anterior second and third as well as the left anterior
third costochondral junctions are present without significant bony
destruction.
IMPRESSION:
1. Supraclavicular, mediastinal, and hilar conglomerate lymph node masses
consistent with recently diagnosed diffuse B-cell lymphoma, overall size has
mildly decreased compared to prior PET-CT from ___.
2. Anterior mediastinal lymph node masses surrounds the ascending aorta out
without vascular invasion.
3. Hilar lymph node masses causes narrowing of the bilateral upper lobe
pulmonary arteries and narrowing of the segmental bronchi, most pronounced in
the left upper lobe.
4. No evidence of pulmonary embolism or aortic abnormality.
5. Multiple pulmonary nodules, some new, some increased, and some decreased
compared to ___ given short-term interval change, findings are likely
infectious.
6. 12 mm hypodense thyroid nodule if clinically indicated a non emergent
thyroid ultrasound can be obtained.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // 43 cm R basilic DL PICC -
___ ___ Contact name: ___: ___
COMPARISON: None available
FINDINGS:
Right PICC terminates in the region of the lower superior vena cava adjacent
to the expected level of the junction with the right atrium. Heart size is
normal. Bilateral mediastinal and hilar widening are concerning for
lymphadenopathy, particularly in the context of bilateral poorly defined
nodular opacities. Note is also made of a small right pleural effusion and
elevation of the right hemidiaphragm. These findings and others have been
more fully delineated by CTA of the chest from the same date.
IMPRESSION:
Right PICC terminates in the lower superior vena cava adjacent to the junction
with the right atrium.
Widespread abnormalities in keeping with history of lymphoma, which have been
more fully characterized by concurrent chest CTA, dictated separately.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with extensive lymphoma lesions including a mass
compressing his biliary tree s/p biliary stent placement ___, now on EPOCH
chemotherapy with rising LFT's. // Evidence of cholelithiasis, patency of
bile duct
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: PET-CT ___.
FINDINGS:
LIVER: The hepatic parenchyma appears slightly 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. Intrahepatic
pneumobilia is noted, expected with an existing ERCP stent. The CBD could not
be visualized due to bowel gas.
GALLBLADDER: Air in the gallbladder. There is no evidence of stones or
gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 10.2 cm.
KIDNEYS: The right kidney measures 10 cm. The left kidney measures 10.7 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. Hepatic steatosis.
2. Expected pneumobilia without intrahepatic duct dilation. The CBD could
not be visualized due to bowel gas.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified, Tachycardia, unspecified
temperature: 97.9
heartrate: 116.0
resprate: 18.0
o2sat: 97.0
sbp: 128.0
dbp: 94.0
level of pain: 4
level of acuity: 2.0 | Brief Hospital course:
====================================
Mr. ___ is a ___ year old male with PMH of asthma, HTN, who
presents due to recent biopsy proven DLBCL/Burkitt's in order to
initiate chemotherapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
morphine
Attending: ___
Chief Complaint:
headache, vertigo, dysarthria, and unsteady gait.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
He states this morning he was making breakfast, getting coffee
ready, when he heard a loud sound, he thought was just inside
his
head. It was similar to stereo feedback. Immediately following
that, he lost control of his R arm. His speech became slurred.
He
was worried he was having a stroke, so he called his friend.
Then
called an ambulance and was brought to ___. His
friend was called around 918 am. He felt dizzy, had difficulty
walking. When he went to bathroom he felt vertigo (spinning) the
whole time, so he laid down on couch. His body felt like it was
falling. He continued to have this feeling for several hours. He
was at ___ around 1000am or so. He had
headache,
it started mild and got worse. It was bitemporal and vice like
feeling. The headache persisted then became more general, it was
in base of skull later. After he got ativan headache resolved,
here. THe headache reached maximal intensity in hours, 1.5-2
hours. The headache seemed the worst around ___. He confirms it
did not reach maximal intensity in seconds or minutes. The
headache started after the vertigo. was lying on couch for about
3 minutes before starting to talk about headaches per his
friend.
The slurred speech lasted until shortly before this interview.
Per his friend, speech was very slurred, like they could not
understand him when he said the word banana. Later on it sounded
more groggy. It was difficult to tell later since he had
received
some sedating medications. He feels speech is almost back to
normal currently. The right hand issues he feels lasted for a
few
hours perhaps. He states arm felt funny, so he tried to make a
small movement to test it, and he was only able to make a large
movement instead. No headaches normally. no similar symptoms
prior.
States he sometimes gets optical migraines, he had one the other
day, they are q8months. no headaches, just visual symptoms.
started when he was ___, it looks like a blob, amorphous, that is
static looking like, it lasts for ___ minutes. it starts in
the
R or L eye then migrates around.
He presented to OSH, ___. CTA h/n and LP were done there.
It was stated that the LP results were significant for "RBC's
30->1000." He was transferred here for neurosurgical evaluation
of possible SAH. He was evaluated by neurosurgery. Neurosurgery
did not feel that presentation was consistent with aSAH and
recommended neurology consult.
Reviewing the notes from ___, regarding the LP it states
that "there was a traumatic tap, so there was a drop of bleed
inside the LP needle which I allowed to clear after about ___
drops. Tube 1 was collected, and then when I was about to
collect
tube 2, I noticed a small amount of blood on the most dependent
area of the LP needle, so I cleared it out with the stylette. I
also allowed about another 10 drops of CSF to drip out and then
obtained tubes 2, 3, and 4. While tube 4 was being collected,
the
patient began to have violent vomiting. Tube 4 was not obviously
bloody."
Labwork from ___ reviewed
Chem7 unremarkable. CBC with Hgb 14.5 WBC 8.4, Plt 249. lactate
was 4.2
There were 1040 RBCs in tube 4. 63 glucose, 33 protein. There
was
no xanthochromia prsent. There was <5 wbcs. I did not
specifically find tube 1 reported in the records, but per ED
notes it had 30 RBCs.
Past Medical History:
Depression
Social History:
___
Family History:
reviewed, noncontributory
denies history of IPH in family, no aneurysms.
no sudden unexpected death
Physical Exam:
Vitals: T97.8 HR86 BP132/71 RR18 Spo2 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE
Vitals: Afebrile, HR ___, BP 100s-120s/60s-70s, RR 15, 97%
No acute distress, breathing comfortably on room air,
extremities
warm and well-perfused, non-edematous.
Awake, alert. Attentive throughout exam. Language fluent
without
errors. VFF to confrontation. No dysarthria. EOM full range and
conjugate. No Nystagmus. Face symmetric. Saccades are brisk and
accurate. Full strength throughout.
No dysmetria or intention tremor on FNF. Subjective
dyscoordination of the right hand that is not appreciable to the
examiner.
Pertinent Results:
___ 05:30PM BLOOD WBC-10.2* RBC-4.28* Hgb-12.9* Hct-39.1*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.2 RDWSD-44.0 Plt ___
___ 05:30PM BLOOD Neuts-84.3* Lymphs-11.9* Monos-3.0*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.56* AbsLymp-1.21
AbsMono-0.30 AbsEos-0.01* AbsBaso-0.02
___ 08:55AM BLOOD ___ PTT-33.9 ___
___ 05:30PM BLOOD Glucose-117* UreaN-10 Creat-0.9 Na-142
K-4.1 Cl-106 HCO3-18* AnGap-18
___ 08:55AM BLOOD Calcium-10.0 Phos-2.5* Mg-2.0
Cholest-226*
___ 08:55AM BLOOD Triglyc-94 HDL-66 CHOL/HD-3.4
LDLcalc-141*
___ 08:55AM BLOOD %HbA1c-5.4 eAG-108
___ 08:55AM BLOOD TSH-1.8
___ 08:55AM BLOOD CRP-1.3
___ Cardiovascular Transthoracic Echo Report
IMPRESSION: Premature appearance of a large amount of agitated
saline contrast in the left heartat rest c/w a patent foramen
ovale/atrial septal defect. Normal biventricular cavity sizes
andregional/global biventricular systolic function. No valvular
pathology or pathologic valvular flowidentified.CLINICAL
IMPLICATIONS:Based on the echocardiographic findings and ___
ACC/AHA recommendations,antibiotic prophylaxis is NOT
recommended
___ Imaging MRV PELVIS W&W/O CONTRA
Wet Read Audit # 2 by ___ on ___ 11:23 ___
There is focal high-grade narrowing of the left common iliac
vein, at its
origin, related to compression from the right common iliac
artery. This
appearance is seen in the context of ___ syndrome
(series 6, image 39 and series 11, image 62). However, there is
no evidence of acute or chronic thrombus in the left common
iliac vein. Furthermore, no thrombus in the IVC, right common
iliac vein, bilateral internal or external iliac veins, and
bilateral common femoral veins.
A phlebolith is suspected within a deep pelvic vein on the right
(series 5
image 32 and series 7 image 72).
___ Imaging MR HEAD W & W/O CONTRAS
FINDINGS:
There are bilateral cerebellar hemispheric acute infarctions
without evidence
of hemorrhage.. There is a associated T2/FLAIR hyperintensity.
There is no evidence of hemorrhage, masses, mass effect or
midline shift. The
ventricles and sulci are normal in caliber and configuration.
There is no
abnormal enhancement after contrast administration.
Intracranial flow voids
are maintained.
IMPRESSION:
Acute infarcts in the cerebellar hemispheres bilaterally. No
evidence of
hemorrhagic transformation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 5 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Escitalopram Oxalate 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Bilateral ischemic cerebellar infarcts
- Patent foramen ovale
- ___ Syndrome
- Hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with no PMH presents with worst headache of life,
associated with vertigo, R hand clumsiness. 1000 RBCs on LP// ?VST, vascular
malformation. Please perform with MPRage sequences
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA head and neck ___.
FINDINGS:
There are bilateral cerebellar hemispheric acute infarctions without evidence
of hemorrhage.. There is a associated T2/FLAIR hyperintensity.
There is no evidence of hemorrhage, masses, mass effect or midline shift. The
ventricles and sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration. Intracranial flow voids
are maintained.
IMPRESSION:
Acute infarcts in the cerebellar hemispheres bilaterally. No evidence of
hemorrhagic transformation.
Radiology Report
EXAMINATION: MRV pelvis with and without contrast
INDICATION: ___ year old man with acute stork in setting of Large ASD// Venous
CLOT***MRV Lower extremities
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 16 mL MultiHance.
COMPARISON: Bilateral lower extremity ultrasound ___.
FINDINGS:
VASCULATURE: There is no evidence of acute or chronic thrombus in the
bilateral common iliac veins, internal or external iliac veins, infrahepatic
IVC, and bilateral common femoral veins.
There are 3 right renal arteries and 2 left renal arteries. The abdominal
aorta is normal in caliber.
RECTUM AND INTRAPELVIC BOWEL: The visualized small and large bowel are normal
in caliber without evidence of obstruction.
BLADDER: Unremarkable.
PROSTATE, SEMINAL VESICLES, AND SCROTUM: Unremarkable.
LYMPH NODES: There is no inguinal or pelvic sidewall lymphadenopathy.
OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions identified.
IMPRESSION:
No evidence of deep venous thrombosis in the pelvis.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with acute stroke in setting of large ASD// DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Headache, Nausea, Transfer
Diagnosed with Dizziness and giddiness
temperature: 97.8
heartrate: 86.0
resprate: 18.0
o2sat: 96.0
sbp: 132.0
dbp: 71.0
level of pain: 4
level of acuity: 2.0 | ___ year old previously healthy presented with an episode of
headache, vertigo, dysarthria, and unsteady gait. He was found
to have bilateral SCA distribution infarcts. He was admitted for
observation and workup for the etiology of these infarcts. LDL
141, A1c 5.4%. Initially, the patient was started on aspirin 81
mg daily. TTE was performed and revealed a PFO. Bilateral LENIs
did not show DVTs; however, MRV of the pelvis was consistent
with ___ Syndrome. Subsequently, the patient was
transitioned from ASA to apixaban 5 mg daily. He was started on
atorvastatin 40 mg daily. He was referred to vascular surgery
for evaluation of ___ and interventional cardiology of
consideration of PFO closure.
TRANSITIONAL ISSUES
- Please ensure follow up with vascular surgery for evaluation
of ___ syndrome and consideration of stenting.
- Please ensure follow up with interventional cardiology for
evalation of PFO and consideration of closure.
-Hypercoagulable labs pending at discharge: Beta-2-Glycoprotein
1 Antibodies and Cardiolipin Antibodies
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 141) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A |
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, weight gain
Major Surgical or Invasive Procedure:
BiPAP initiation
History of Present Illness:
___ hx asthma, obesity, OSA, ___ (EF ___, pulmonary
hypertension, RV failure, chronic respiratory failure (3L home
O2) who presents with worsening dyspnea and weight gain.
She was seen in ___ ___ for evaluation after developing 20#
weight gain over 6 weeks. She also developed worsening rest and
exertional dyspnea. Denies worsening chest pain and leg
swelling. In ___ note, providers report that patient ran out of
her medications and had not been taking home antihypertensives
or furosemide. These medications were prescribed, and she took
20mg PO Lasix once on ___ without effect. Due to worsening
dyspnea, weight gain she presented to ED for eval.
In the ED:
- Initial VS (no temp) 81 161/92 25 92% Nasal Cannula
- Labs: Chem normal except HCO3 30, BUN/Cr ___. BNP 659. CBC,
coags, LFTs, UA unremarkable.
- Studies: CXR with "Unchanged moderate to severe cardiomegaly
with mild to moderate pulmonary edema." ECG demonstrates sinus
rhythm, ___, poor baseline but no apparent ST segment
deviations.
- Interventions:
___ 16:46 PO Aspirin 324 mg ___
___ 18:24 IV Furosemide 40 mg ___
- Consults: none
She is admitted to Cardiology for further management.
VS prior to transfer
On the floor, she recounts the history above. She complains of
HA without visual changes. She has dyspnea for years but several
weeks of worsening exertional dysnpea, decreased exercise
tolerance, and fatigue. She has ___ orthopnea at baseline
for years, which hasn't changed. She reports only intermittent
medication adherence due to her primary care doctor leaving
___ (Dr. ___ and not having a new PCP. Today, she was able
to take amlodipine and spironolactone, but has not been taking
lisinopril or metoprolol for the past several weeks.
She notes she has been on home oxygen for several years, but
does not recall anyone ever giving her a diagnosis for why she
has chronic respiratory failure. She wears O2 all the time. On
review of OMR, it appears she carries dx of pulmonary HTN
(likely made on the basis of echo), but she has not specifically
seen cardiology, pulmonology, or had RHC for this.
She also carries dx of OSA. She has had 2 sleep studies. The
first one resulted in CPAP being prescribed; she used it
temporarily but found it too burdensome. The second sleep study
resulted in her being told she required BiPAP, but she was never
able to get the machine.
Past Medical History:
- dCHF
- HTN
- OSA
- asthma
- obesity
- migraines
- anemia
- uterine fibroids
- ventral hernia
- depression
- umbilical hernia repair ___
- incisional hernia repair ___ with LOA, L adnexal drain
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ HYPERTENSION
STROKE
EPILEPSY
Father Living ___ MOUTH CANCER Dx'd at age ___.
Sister Living
Comments: No early deaths. No cancers of the breast, lung,
colon, endometrium or ovaries. No MI.
Physical Exam:
==============
ADMISSION EXAM
==============
VS 99.3 174/117 84 24 91/3L (home O2). Repeat BP 130s systolic
Genl: morbidly obese, NAD
HEENT: PERRLA, no icterus, MMM
Neck: JVP difficult to appreciate given habitus
Cor: RRR. II/VI SEM loudest over the aortic area.
Pulm: distant breath sounds, equal air entry bilaterally. ?
crackles at bilateral lung bases.
Abd: obese, nt
MSK: 2+ pitting edema to the knee bilaterally
Neuro: alert, oriented x3. grossly nonfocal.
Skin: R shin with area of superficial skin breakdown
==============
DISCHARGE EXAM
==============
***
Pertinent Results:
==============
ADMISSION LABS
==============
___ 04:15PM BLOOD ___
___ Plt ___
___ 04:15PM BLOOD ___
___ Im ___
___
___ 04:15PM BLOOD Plt ___
___ 04:15PM BLOOD ___
___
___ 04:15PM BLOOD ___
___ 04:15PM BLOOD ___
___ 06:10AM BLOOD ___
___ 04:35PM BLOOD ___
___ 04:35PM BLOOD O2 ___
=================
PERTINENT IMAGING
=================
CXR PA AND LATERAL (___): Unchanged moderate to severe
cardiomegaly with mild to moderate pulmonary edema.
ECHOCARDIOGRAM (___): The left atrium and right atrium are
normal in cavity size. There is mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size is normal
with mild global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Moderate pulmonary artery
systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function
Compared with the prior study (images reviewed) of ___,
moderate PA systolic hypertension is now quantified.
RLE VENOUS ULTRASOUND (___):
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. 5.2 ___ cyst on the right.
==============
DISCHARGE LABS
==============
***
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
8. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
Discharge Medications:
1. Torsemide 20 mg PO DAILY
RX *torsemide 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing sob
5. Amlodipine 10 mg PO DAILY
6. Betamethasone Dipro 0.05% Oint 1 Appl TP DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Spironolactone 25 mg PO DAILY
9.Outpatient oxygen
Oxygen concentrator with portable O2 via nasal cannula.
___: R09.02, E66.2, J96.11. Flow: 3 liters/minute.
Length of need: ongoing. Ordering Provider: ___ MD,
___ #: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- diastolic heart failure, acute on chronic
- obstructive sleep apnea
- pulmonary hypertension
- morbid obesity
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 hypoxia, shortness of breath, weight gain //
pulmonary edema edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Moderate to severe cardiomegaly is re- demonstrated, unchanged. The
mediastinal contour appears similar. Perihilar haziness is present along with
mild to moderate pulmonary edema, similar to that seen on the prior study. No
large pleural effusion, focal consolidation, or pneumothorax is present.
There is probable bibasilar atelectasis. No acute osseous abnormalities
detected.
IMPRESSION:
Unchanged moderate to severe cardiomegaly with mild to moderate pulmonary
edema.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with RLE > LLE // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Right lower extremity Doppler ultrasound ___
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.
There is ___ cyst in the right popliteal fossa measuring approximately 5.2
x 0.7 x 2.6 cm.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 5.2 ___ cyst on the right.
Gender: F
Race: HISPANIC/LATINO - CUBAN
Arrive by WALK IN
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Heart failure, unspecified
temperature: nan
heartrate: 92.0
resprate: nan
o2sat: 77.0
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 2.0 | ___ hx asthma, obesity, OSA, dCHF (EF ___, and hx
sonographic RV dysfunction who presented with worsening heart
failure symptoms. She was diuresed to euvolemia but still had
exertional desaturation to the high ___ she therefore underwent
RHC which showed normal RA pressures but mild pulmonary HTN
(mRAP 6, mPAP 26, PCWP 7, PVR 3.0 ___. She had TTE with bubble
study which had indeterminate results due to body habitus. Due
to persistent ambulatory hypoxemia (ambo SaO2 ___, she was
discharged with home oxygen.
Additionally, for OSA and obesity hypoventilation, she was seen
by Pulmonology consult. She received BiLevel nocturnal
respiratory support, and was set up for this at home. She was
also encouraged to follow up with bariatric surgery.
=============
ACTIVE ISSUES
=============
# HFpEF: Presented with 3L O2 requirement, exertional dyspnea.
Diuresed to euvolemia with IV Lasix, then started on oral
medications. TTE this admission confirmed normal EF.
- Preload: torsemide 20 daily
- see OSA below
# OSA:
# Possible pulmonary HTN:
s/p 2 sleep studies: Sleep study #1 recommended CPAP, which the
patient received and has not been using; sleep study #2
recommended BiPAP with IPAP 19 EPAP 16. She was unable to get
the BiPAP due to logistical issues. Her OSA is complicated by hx
of sonographic findings of RV overload/failure (free wall
dilation and hypokinesis), raising concern for WHO3 pulmonary
HTN.
- Pulmonology consulted for assistance with nocturnal
respiratory support
- patient started on BiPAP QHS IPAP 19 EPAP 16
- arranged this admission for outpatient nocturnal BiLEVEL
- due to persistent ambulatory desaturation to low ___
(attributed to obesity hypoventilation), she was arranged for
home oxygen therapy; by report from the nursing staff, she
declined O2 when it was delivered to her home
- had RHC after diuresis to euvolemia, showing: RA 2, RV ___ PA
___ (26) PCWP 7 CO 6.4 CI 2.27, PVR 3.0. Elevated TPG suggests
an element of pulm HTN
- RV overload: Diuretics as above. NHBK with metoprolol
succinate 75 daily. cont'd spironolactone 25 daily.
# Morbid obesity:
Patient's morbid obesity complicating her HFpEF, OSA. Likely a
significant contributor to her ambulatory hypoxemia. She has
followed with bariatric surgery in the past.
- encouraged patient to follow up with Bariatric Surgery
# HTN: Elevated on admission, likely ___ nonadherence. Pt was
resumed on a lower dose of her antihypertensives (amlodipine
10mg and lisinopril 10mg daily), to improvement of her BP.
=====================
CHRONIC/STABLE ISSUES
=====================
# ASTHMA: Continued home albuterol, fluticasone
===================
TRANSITIONAL ISSUES
===================
- follow up: CHF, Pulm (OSA, obesity hypovent), Bariatric Surg,
PCP
- needs home nocturnal resp support (set up in hospital)
- needs ambulatory oxygen supplementation due to exertional
desat to ___.
- needs further diagnosis and treatment of exertional hypoxemia
- needs to undergo weight loss to improve her cardiopulmonary
status and overall prognosis; has considered bariatric surgery
in the past
- CODE: FULL
- contact/HCP: ___, nephew, ___
- dry weight: 219 kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
AMS, lactic acidosis
Major Surgical or Invasive Procedure:
___: Right Internal Jugular Insertion
intubation
History of Present Illness:
Mr. ___ is a ___ y/o male with history of questionable
schizophrenia and previous Benadryl overdose, who presented with
AMS.
The patient was reportedly at his baseline health until this
morning. The patient had called his friend two days prior to
admission stating that he was going to stay with him. When he
asked why he was coming to ___, the patient stated that he
would tell the friend later. He told the friend he was going
to ___ to get cold medication and then never returned. He
was noted to be acting erratically and vomiting after entering
the College of ___. He was reportedly found with a receipt
for 150 pills of naproxen. EMS was called and brought the
patient to the emergency department.
In the ED, his friend also provided prior ___ paperwork
describing a prior psychiatric illness and prior Benadryl
overdose, admitted to ___ (___). At that time, the patient
had been having paranoid delusions of persecution. He then
overdosed on Benadryl and was admitted to ___. He was started
on olanzapine 10mg PO qhs at that time.
In the ED, initial vitals: Temp 98.8 HR 112 BP 118/80 RR 12
100% on RA
Exam notable for: pupils 4 mm reactive, armpits not dry, no
clonus, not speaking at all, actively avoiding the examiner
Labs notable for: Cr 1.0, WBC 24.4, CK 362, lactate 9.4 -> 7.3,
urine/serum tox negative, VBG ___
QTc 517
Imaging: CXR negative, CT head negative for acute process
Patient received: 1L NS, 5L LR cefepime/vancomycin,
dexamethasone 10 mg, lorazepam 1 mg, ketamine 70 mg, and was
started on norepinephrine
Consults: Poison control who recommended supportive measures
Patient became acute altered and began vomiting in the ED. He
was given ketamine and intubated for airway protection.
Vitals on transfer: Temp 97.8 HR 110 BP 94/42 RR 15 100% on
ventilator
Upon arrival to ___, unable to obtain further information as
patient intubated and sedated.
Past Medical History:
- Possible Schizophrenia
- Possible prior suicide attempt
Social History:
___
Family History:
Unable to obtain due to mental status
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.1, HR 110, BP 129/92, 100% intubated
GENERAL: WDWN male in NAD. Lying comfortably. Sedated.
HEENT: Sclera anicteric, Pupils pinpoint MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Normal respiratory effort. rhonchi bilaterally
CV: tachycardic, normal rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness
EXT: cool, 2+ pulses, no clubbing, cyanosis or edema
SKIN: Warm, dry. No rashes.
NEURO: Sedated.
ACCESS: 3 PIVs
DISCHARGE PHYSICAL EXAM:
========================
Examined 1030 AM
VSS
GENERAL: sitting in bed, alert, nad
HEENT: Sclera anicteric
NECK: JVP not elevated, no LAD
LUNGS: Normal respiratory effort. CTAB
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness
EXT: cool, 2+ pulses, no clubbing, cyanosis or edema
SKIN: Warm, dry. No rashes.
NEURO: alert, oriented, nonfocal
PYSCH: paranoid, no SI/HI, very calm and pleasant otherwise
Pertinent Results:
ADMISSION LABS:
================
___ 01:45PM BLOOD WBC-24.4* RBC-5.35 Hgb-15.1 Hct-46.1
MCV-86 MCH-28.2 MCHC-32.8 RDW-14.3 RDWSD-45.1 Plt ___
___ 01:45PM BLOOD Neuts-90.7* Lymphs-4.8* Monos-2.9*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-22.12* AbsLymp-1.17*
AbsMono-0.70 AbsEos-0.02* AbsBaso-0.07
___ 01:45PM BLOOD Plt ___
___ 04:15PM BLOOD ___ PTT-26.9 ___
___ 01:45PM BLOOD Glucose-197* UreaN-10 Creat-1.0 Na-138
K-5.9* Cl-101 HCO3-20* AnGap-17
___ 01:45PM BLOOD ALT-QNS AST-QNS AlkPhos-75 TotBili-0.2
___ 01:45PM BLOOD Lipase-31
___ 04:15PM BLOOD CK-MB-12* MB Indx-3.3
___ 01:45PM BLOOD Albumin-4.4 Calcium-9.4 Phos-5.0* Mg-2.5
___ 06:19PM BLOOD Osmolal-308
___ 10:32PM BLOOD TSH-4.4*
PERTINENT LABS/MICRO:
======================
___ 01:45PM BLOOD Lipase-31
___ 10:32PM BLOOD cTropnT-<0.01
___ 12:10PM BLOOD CK-MB-18* MB Indx-7.3* cTropnT-<0.01
___ 10:32PM BLOOD TSH-4.4*
___ 12:10PM BLOOD HIV Ab-NEG
___ 04:17PM BLOOD Lactate-9.4*
___ 06:31PM BLOOD Lactate-7.3*
___ 11:39PM BLOOD Lactate-3.1* K-3.5
___ 04:16AM BLOOD Lactate-2.6*
___ 10:55PM BLOOD Lactate-1.7
___ 06:31PM BLOOD Type-CENTRAL VE pO2-42* pCO2-41 pH-7.36
calTCO2-24 Base XS--1 Intubat-NOT INTUBA
___ 04:27PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 10:35PM BLOOD Tricycl-NEG
___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 6:19 pm Blood (LYME)
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
___ BCX x2: No growth to date
___ 6:01 pm CSF;SPINAL FLUID #3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
___ Urine culture: No growth
DISCHARGE LABS:
================
PERTINENT IMAGING:
==================
___: CT HEAD WITHOUT CONTRAST
No acute intracranial abnormality. Prominence of the ventricles
and sulci, consistent with involutional changes, is greater than
that typically seen in a patient of this age.
___ CXR
No acute intrathoracic process.
___ 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
normal left ventricular diastolic function. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal biventricular systolic function. No
pathologic valvular flow.
Medications on Admission:
n/a
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
3. OLANZapine 5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
toxic ingestion
?suicide attempt
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 AMS// bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 14.6 cm; CTDIvol = 48.1 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction, hemorrhage, edema,
or mass. The ventricles and sulci are more prominent than typically expected
in a patient of this age, consistent with involutional changes.
No fractures identified. Partially imaged paranasal sinuses are clear. The
mastoid air cells and middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality. Prominence of the ventricles and sulci,
consistent with involutional changes, is greater than that typically seen in a
patient of this age.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with AMS// pna
COMPARISON: None
FINDINGS:
AP semi-upright view of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ intubated eval ett position// ___ intubated eval ett position
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 17:00.
IMPRESSION:
Compared to the earlier same day examination, there has been intervention with
the endotracheal tube tip terminating 3 cm cranial to the carina,
satisfactory. There has also been placement of an upper enteric tube curled
with the tip terminating over the gastric fundus, satisfactory. Lung volumes
remain low. No other short-term interval changes are seen.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: ___ year old man with new R IJ CVL// new CVL placement Contact
name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiographs from ___.
FINDINGS:
There is a new right internal jugular central venous line, which terminates in
the right atrium. Endotracheal tube tip terminates approximately 4 cm above
the carina. Enteric tube is curled in the stomach.
Lung volumes remain low, exaggerating the cardiomediastinal silhouettes. No
new focal consolidations are seen. There is no pulmonary edema or pleural
abnormality.
IMPRESSION:
New right internal jugular central venous line terminates in the right atrium.
If desired position is in the cavoatrial junction, recommend withdrawing by
2.5 to 3.0 cm.
NOTIFICATION: The findings recommendations were discussed with ___
___, MD, on the telephone by ___, MD, on ___ at 23:13.
Radiology Report
INDICATION: ___ year old man with new cvl now pulled back 2.5 cm// assess
position of cvl Contact name: ___: ___
TECHNIQUE: Chest portable AP
COMPARISON: ___, 22:34
FINDINGS:
The lungs are clear and well expanded. No consolidation or atelectasis. No
pleural effusion or pneumothorax. No change the position of the various tubes
with NG tube terminating in the stomach, ET tube terminating above the carina,
and right IJ line terminating in the distal SVC.
IMPRESSION:
No active disease.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Poisoning by unsp drug/meds/biol subst, accidental, init, Vomiting without nausea, Oth places as the place of occurrence of the external cause, Altered mental status, unspecified
temperature: nan
heartrate: 109.0
resprate: 22.0
o2sat: 100.0
sbp: 128.0
dbp: 80.0
level of pain: uta
level of acuity: 2.0 | Mr. ___ is a ___ y/o male with history of questionable
schizophrenia and previous Benadryl overdose, who presented with
AMS likely secondary to toxic ingestion. He initially required
intubation given AMS and MICU admission. He was given
intravenous fluids and monitored clinically and with serial
EKGs.
ACTIVE ISSUES:
===============
# Encephalopathy:
Presented by EMS after noted to be acting erratically and AMS.
Highest concern for toxic ingestion, particularly given his
possible previous overdose and acute change in mental status.
Serum/urine tox and TCA screen negative. There was concern for
overdose of naproxen given a receipt found on him or a cold
medication given history provided but no other signs of
anticholinergic toxicity such as urinary retention or flushing
besides AMS and prolonged QTc in ED. Poison control was
consulted and recommended continuing with conservative measures.
He was also monitored with serial EKGs that showed a downtrended
QTc from ~500s initially to <500. Differential also included
infection with leukocytosis to 24 though there were no focal
signs or symptoms and work up, including cultures and LP, was
unremarkable. He received wide spectrum antibiotics and IV
acyclovir for possible HSV encephalitis for 2 days before
stopping given low clinical concern. EEG performed which did
reveal possible focus of epileptiform activity but he couldn't
tolerate leads so EEG was DCd and Neuro recommends no
intervention. His mental status ultimately improved rapidly and
he was extubated without issues. When he was more coherent he
reports he is unable to remember what happened to bring him to
the hospital. He denied any intentional overdose but did admit
to taking 4 unisom pills has he hadn't slept for 3 days.
Currently appears to be at baseline mental status.
# Possible Schizophrenia:
# Possible prior suicide attempt:
# Possible ingestion, presumed intentional
Appears to on initial reports to have a 2 week hospitalization
requiring inpatient psych admission under similar circumstances
at ___. Reportedly on Olanzapine but reports he has stopped
taking it a few months, unclear how true this is.
Toxicology recommended conservative management for possible
NSAID ingestion and has no further symptoms. He reports he took
some unisom pills ~4 pills. Vitals and labs have since
normalized so toxicology recommended against any further
evaluation. Currently denies SI or previous SI. He does report
hearing voices which he denies tells him to hurt himself or
others but rather just speaks to others about what he does. He
said he last heard the voices a few day prior to admission. He
was evaluated by psychiatry who given admission circumstances
were concerned for possible intentional overdose in suicide
attempt. He was sectioned and monitored on 1:1 supervision. He
was transferred to inpatient psychiatry.
#Acute hypoxic respiratory failure
#Aspiration pneumonitis
In the ED, patient vomited, likely aspirated, and then became
hypoxic. Gastric secretions suctioned from oropharynx and OG
tube. He was intubated given ongoing hypoxia and AMS. Follow up
CXR was overall unremarkable. He was briefly treated with broad
spectrum antibiotics for ~2 days before discontinuing due to low
concern for true infection. He was continued on a ventilator
for ~36-48 hours before being extubated without issues.
Currently saturating well on RA.
#Lactic Acidosis
#Anion Gap Metabolic Acidosis
#Leukocytosis
Meet ___ SIRS criteria (HR, WBC) with lactic acidosis to 9.4 on
arrival. Combination concerning for infection though ingestion
was felt to be more likely given his history. CXR unremarkable.
Cultures negative. LP unremarkable. Ultimately, lactic acidosis
improved with significant fluid resuscitation. Was placed on
broad spectrum abx for 48hrs that have since been removed. He
has been afebrile without leukocytosis and off abx for >48hrs
with no worsening of symptoms.
# Coagulopathy
INR of 1.7 without clear etiology, possibly related to ingestion
though LFTs otherwise normal, tylenol level negative. No signs
of bleeding. Downtrended to 1.1 by discharge.
___ weakness- He reports ___ weakness and RUE weakness. Exam is
not consistent with reported weakness. He told toxicology he had
back issues because he was stabbed prior to coming to the
hospital. Wonder if he has some discomfort from LP that he is
manifesting with his new "disability" as his symptoms don't
appear to correlate with examine findings. He eventually was
able to ambulate on his own. Per psych request ___ was consulted
who cleared him for discharge.
Direct patient care, discharge planning and care coordination,
discussion with consultants took approx. 40 min on day of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
epinephrine
Attending: ___.
Chief Complaint:
pain in both legs
Major Surgical or Invasive Procedure:
___: Bilateral groin exploration ; right superficial
femoral artery and popliteal embolectomy; left superficial
femoral artery, popliteal and profunda embolectomy.
History of Present Illness:
The patient is a ___ female with known
AFib on a beta-blocker for rate control, and anticoagulated with
Coumadin. She presented to an outside facility with complaints
of
sharp, new onset of bilateral lower extremity pain. She was
worked up and found to have bilateral embolism to the
popliteal artery as well as to the left profunda. She was
subtherapeutic with an INR of 1.4. She was started on heparin
and sent to ___ for further work up. Upon admission
plans were made to take her to the OR urgently.
Past Medical History:
mitral valve prolapse ___, paroxismal a-fib following mitral
valve repair, s/p 4 cardioversions, on lifelong coumadin therapy
PSH: ovarian cystectomy & appy ___ yrs ago, IMN
left tibia after MVA ___ yrs ago, mitral valve repair ___ BWH,
lap LOA ___ for SBO
Social History:
___
Family History:
non contributory
Physical Exam:
Gen: WDWN in nad
CV: irreg rhythm
Lungs: CTA bilat
Abd: Soft non tender
Extremities: Bilat groin incisions c/d/i
RLE: p/d/d/d; LLE:p/d/p/d
Pertinent Results:
___ 09:30AM BLOOD WBC-9.3 RBC-3.23* Hgb-10.1* Hct-29.1*
MCV-90 MCH-31.3 MCHC-34.9 RDW-12.5 Plt ___
___ 09:30AM BLOOD Glucose-131* UreaN-9 Creat-0.6 Na-140
K-3.6 Cl-105 HCO3-27 AnGap-12
___ 09:30AM BLOOD Calcium-8.4 Phos-1.1* Mg-2.0
___ 09:30AM BLOOD ___ PTT-32.6 ___
___ 05:10AM BLOOD ___ PTT-34.6 ___
___ 06:25PM BLOOD ___ PTT-35.4 ___
___ 09:45AM BLOOD ___ PTT-150* ___
___ 02:59AM BLOOD ___ PTT-150* ___
___ 06:55PM BLOOD ___ PTT-29.8 ___
___ 10:22 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO 4 TABLETS BEFORE DENTAL PROCEDURE
2. clotrimazole-betamethasone ___ % Topical PRN
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Simvastatin 10 mg PO DAILY
6. Warfarin 7.5 mg PO DAILY16
7. Calcium Carbonate 600 mg PO DAILY
8. B Complex (B complex vitamins) Oral daily
Discharge Medications:
1. Calcium Carbonate 600 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*0
3. Simvastatin 10 mg PO DAILY
4. Warfarin 7.5 mg PO DAILY16
check INR daily
5. Amoxicillin 500 mg PO 4 TABLETS BEFORE DENTAL PROCEDURE
6. B Complex (B complex vitamins) 0 tab ORAL DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. clotrimazole-betamethasone ___ % Topical PRN
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
once a day Disp #*30 Tablet Refills:*11
10. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q4-6h
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with bilateral lower extremity embolism.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left lower extremity coolness, concern for clot, history of AFib.
COMPARISON: None available.
TECHNIQUE: MDCT images were obtained from the aortic bifurcation to the toes
before and following the administration of IV contrast.
Coronal and sagittal reformations were performed. 3D and reconstructions were
performed on a separate workstation.
FINDINGS:
PELVIS: The uterus is normal. There is a 2.2-cm cyst in the left ovary. The
right ovary is normal. Visualized small and large bowel are unremarkable.
The rectum is normal. The bladder is normal. There is no free fluid in the
pelvis.
CTA PELVIS: The distal aorta, both common, both internal and both external
iliac arteries are widely patent. No aneursym or signficant atherosclerotic
disease is seen.
CTA RIGHT LOWER EXTREMITY: The common femoral, superficial femoral and deep
femoral arteries are widely patent. There is an occlusion of the mid
popliteal artery extending inferiorly into the tibioperoneal trunk and
proximal anterior tibial artery. There is reconstitution of the proximal
anterior tibial artery, just distal to its origin, but flow peters out
distally, just proximal to the ankle. Only a portion of the proximal and mid
peroneal artery is reconstituted but demonstrates occlusion distally. The
proximal posterior tibial artery is reconsitituted proximally and demonstrates
normal opacification down to the foot.
LEFT LOWER EXTREMITY: The common femoral artery is widely patent. There is
occlusion of the proximal deep femoral artery just after its origin. The
proximal and mid superficial femoral artery are widely patent. There is
occlusion of the distal superfical femoral and popliteal artery. There is
reconstitution of flow at the tibioperoneal trunk and the proximal anterior
tibial artery. The posterior tibial artery is opacified to the level of the
foot. The proximal anterior tibial artery appears to be occluded beyond its
midpoint, with non-opacification of the distal artery. The peroneal artery is
occluded distally, proximal to the ankle joint.
BONES: There is a left tibial intramedullary rod. Otherwise the bones are
grossly unremarkable.
IMPRESSION:
1. Occlusion involving the right mid popliteal artery with reconstitution of
flow distally to the foot via the posterior tibial artery. The anterior tibial
and peroneal arteries are occluded distally, proximal to the ankle.
2. Occlusion of the left deep femoral artery proximally, just distal to its
origin.
3. Occlusion of the distal left superior femoral artery and popliteal artery
with reconstitution distally to the foot via the posterior tibial artery. Mid
and distal anterior tibial artery and distal peroneal arteries are occluded.
4. 2-cm left adnexal cyst; given the patient's postmenopausal status,
recommend pelvic ultrasound for further evaluation.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: L LEG PAIN
Diagnosed with LOWER EXTREMITY EMBOLISM, LONG TERM USE ANTIGOAGULANT, HEART VALVE REPLAC NEC
temperature: 99.0
heartrate: 81.0
resprate: 16.0
o2sat: 99.0
sbp: 123.0
dbp: 86.0
level of pain: 2
level of acuity: 2.0 | Ms. ___ was admitted and started on a heparin gtt. She
underwent bilateral groin explorations, right superficial
femoral artery and popliteal embolectomy,left superficial
femoral artery, popliteal and profunda embolectomy on ___. She
tolerated the procedure well, recovered in the PACU and then
transfered to the VICU. She was monitored closely and did very
well. She was continued on a heparin gtt and her coumadin was
restarted. Heparin was discontinued when INR was therapeutic.
Her SBP was in the ___ and ___ and her toprol was weaned to a
smaller dose. She had a vagal event and ultimately was
transitioned to metoprolol 12.5mg bid. She otherwise did well.
She was tolerating a regular diet, and ambulating at baseline.
She was stable for discharge home on ___. She will follow up
with vascular for staple removal, and with her pcp and
cardiologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 01:35PM BLOOD WBC-6.8 RBC-2.41* Hgb-8.4* Hct-25.0*
MCV-104* MCH-34.9* MCHC-33.6 RDW-23.3* RDWSD-85.3* Plt ___
___ 01:35PM BLOOD Neuts-56.8 ___ Monos-12.6
Eos-0.4* Baso-0.4 NRBC-0.7* Im ___ AbsNeut-3.86
AbsLymp-2.00 AbsMono-0.86* AbsEos-0.03* AbsBaso-0.03
___ 01:35PM BLOOD ___ PTT-34.5 ___
___ 01:35PM BLOOD Glucose-90 UreaN-19 Creat-1.0 Na-150*
K-3.7 Cl-125* HCO3-10* AnGap-15
___ 01:35PM BLOOD ALT-21 AST-37 AlkPhos-106* TotBili-2.8*
___ 01:35PM BLOOD Lipase-39
___ 01:35PM BLOOD cTropnT-<0.01
___ 11:27PM BLOOD cTropnT-0.01
___ 01:35PM BLOOD Albumin-2.6* Calcium-8.4 Phos-5.0*
Mg-1.5*
___ 01:38PM BLOOD Ammonia-71*
___ 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:42PM BLOOD ___ pO2-39* pCO2-16* pH-7.42
calTCO2-11* Base XS--10
___ 07:12PM BLOOD ___ pO2-35* pCO2-14* pH-7.46*
calTCO2-10* Base XS--10
___ 11:41PM BLOOD ___ pO2-103 pCO2-15* pH-7.45
calTCO2-11* Base XS--9
___ 11:51PM BLOOD ___ pO2-275* pCO2-19* pH-7.34*
calTCO2-11* Base XS--12 Intubat-INTUBATED
___ 01:42PM BLOOD Lactate-2.6*
___ 06:50PM BLOOD Lactate-3.0*
___ 11:41PM BLOOD Lactate-4.0*
___ 02:30PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
OTHER PERTINENT LABS
====================
___ 04:02AM BLOOD Osmolal-315*
___ 08:28AM BLOOD ___ pO2-49* pCO2-26* pH-7.39
calTCO2-16* Base XS--7
___ 03:52AM BLOOD Lactate-1.8
___ 06:21AM BLOOD Lactate-1.6
___ 08:28AM BLOOD Lactate-1.5
___ 09:40AM BLOOD Lactate-1.0
___ 12:02PM BLOOD ___
___ 08:35AM BLOOD ___
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-8.1 RBC-2.26* Hgb-7.6* Hct-22.9*
MCV-101* MCH-33.6* MCHC-33.2 RDW-21.8* RDWSD-76.5* Plt ___
___ 06:10AM BLOOD ___ PTT-47.2* ___
___ 06:10AM BLOOD Glucose-83 UreaN-9 Creat-0.8 Na-138 K-4.0
Cl-113* HCO3-16* AnGap-9*
___ 06:10AM BLOOD ALT-13 AST-23 AlkPhos-75 TotBili-2.1*
___ 06:10AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
MICRO
=====
___ 4:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:02 am URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 9:55 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 9:55 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
___ 4:02 am URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 04:02AM URINE Streptococcus pneumoniae Antigen
Detection - negative
IMAGING
=======
CXR ___
AP portable upright view of the chest. Port-A-Cath resides over
the right
chest wall with catheter tip in the mid SVC. Overlying EKG
leads are present.
Vague opacity at the left lateral lung base on the frontal view
likely
represents pleural thickening as seen on prior CT. The lungs
are otherwise
clear without consolidation, large effusion, pneumothorax.
Cardiomediastinal
silhouette appears stable. Imaged bony structures are intact.
CT head ___
There is no evidence of fracture, acute major
infarction,hemorrhage,edema,or discrete mass. There is
prominence of the ventricles and sulci suggestive of
involutional changes. There is redemonstration of mild
periventricular white matter hypodensities, nonspecific but
likely representing chronic microvascular ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized
portion of the orbits are normal.
CXR ___
Right chest wall Port-A-Cath is again seen. Chronic blunting of
the right
lateral costophrenic angle likely due to pleural thickening.
The lungs are clear without consolidation, effusion, or edema.
Cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
CXR ___. New enteric tube terminates in the stomach with side hole at
the level of
the diaphragm. This should be advanced by approximately 8 cm.
2. Endotracheal tube in appropriate position.
3. New right basilar opacity may represent aspiration, less
likely
atelectasis.
CXR ___. Enteric tube side port is likely above the gastroesophageal
junction and
advancement by approximately 9 cm is recommended.
2. Endotracheal tube is appropriately positioned.
3. Persistent right basilar airspace opacity.
CXR ___
-Interval advancement of the enteric tube, which now terminates
within the
body the stomach.
-New opacities within the right lung base could be seen in
setting of
infection/aspiration.
-Persistent mild pulmonary vascular congestion.
RUQUS ___. Cirrhotic liver. No focal suspicious hepatic mass is
identified.
2. Sequelae of portal hypertension including reversal of flow in
the main
portal vein (hepatofugal) and splenic vein and present
splenorenal
collaterals.
3. Cholelithiasis without sonographic evidence of cholecystitis.
CXR ___. Nasogastric tube terminates in the stomach.
2. Unchanged mild pulmonary vascular congestion.
3. Unchanged right lower lobe opacity, which may be secondary to
infection or aspiration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. FoLIC Acid 1 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lisinopril 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nicotine Patch 14 mg/day TD DAILY
9. rifAXIMin 550 mg PO BID
10. Sodium Bicarbonate 650 mg PO BID
11. Thiamine 100 mg PO DAILY
12. Dexamethasone 4 mg PO 1 TABLET(S) BY MOUTH TWICE A DAY 2
DAYS AFTER CHEMOTHERAPY
13. LORazepam 0.5 mg PO Q8H:PRN needed for nausea, anxiety,
insomnia
14. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
15. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
16. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
17. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
to be completed ___ AM
2. Sodium Bicarbonate 1300 mg PO BID
3. Thiamine 200 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Dexamethasone 4 mg PO 1 TABLET(S) BY MOUTH TWICE A DAY 2
DAYS AFTER CHEMOTHERAPY
6. FoLIC Acid 1 mg PO DAILY
7. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
9. Lactulose 30 mL PO TID
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Lisinopril 5 mg PO DAILY
12. LORazepam 0.5 mg PO Q8H:PRN needed for nausea, anxiety,
insomnia
should not take if confused
13. Multivitamins 1 TAB PO DAILY
14. Nicotine Patch 14 mg/day TD DAILY
15. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
16. rifAXIMin 550 mg PO BID
17. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
18. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you see your doctor
19.Outpatient Lab Work
ICD-10: E83.39, E87. 2
Complete Metabolic Panel(Na, K, Cl, HCO3, BUN, Cr, Glucose, Ca,
Mg, Phos)
Please fax results to ___ (liver clinic), attention:
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Hepatic Encephalopathy
Aspiration Pneumonia
Secondary Diagnosis: Decompensated Alcoholic Cirrhosis
Acute Kidney Injury
Hypernatremia
Melena
Acute on Chronic Anemia
Lactic Acidosis
Acid-Base Disturbance
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 tachypnea, cough // ?pna, acute process
COMPARISON: Prior exam is dated ___
FINDINGS:
AP portable upright view of the chest. Port-A-Cath resides over the right
chest wall with catheter tip in the mid SVC. Overlying EKG leads are present.
Vague opacity at the left lateral lung base on the frontal view likely
represents pleural thickening as seen on prior CT. The lungs are otherwise
clear without consolidation, large effusion, pneumothorax. Cardiomediastinal
silhouette appears stable. Imaged bony structures are intact.
IMPRESSION:
Port-A-Cath appears well positioned. No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with ams, r/o bleed // ams, 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. Due to motion, images were
repeated.
DOSE: Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: CT head dated ___
FINDINGS:
There is no evidence of fracture, acute major infarction,hemorrhage,edema,or
discrete mass. There is prominence of the ventricles and sulci suggestive of
involutional changes. There is redemonstration of mild periventricular white
matter hypodensities, nonspecific but likely representing chronic
microvascular ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
IMPRESSION:
No acute intracranial findings.
Radiology Report
INDICATION: ___ with ? pulm edema, SOB // ? pulm edema
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___ at 1:28 p.m.. Chest CT from ___.
FINDINGS:
Right chest wall Port-A-Cath is again seen. Chronic blunting of the right
lateral costophrenic angle likely due to pleural thickening. The lungs are
clear without consolidation, effusion, or edema. Cardiomediastinal silhouette
is stable. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ETT*** WARNING *** Multiple patients with same
last name! // ETT
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph dated ___ at 20:00
FINDINGS:
There has been interval placement of an endotracheal tube terminating 2.4 cm
above the carina. There is a new enteric tube terminating in the stomach with
side hole at the level of the diaphragm. Right-sided Port-A-Cath is
unchanged. The cardiomediastinal silhouette is unremarkable. New opacity in
the right lung base. There is no pleural effusionor pneumothorax.
IMPRESSION:
1. New enteric tube terminates in the stomach with side hole at the level of
the diaphragm. This should be advanced by approximately 8 cm.
2. Endotracheal tube in appropriate position.
3. New right basilar opacity may represent aspiration, less likely
atelectasis.
NOTIFICATION: Findings were communicated with ___, MD by ___
___, MD via telephone on ___ at 23:38
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with ogt placemnt*** WARNING *** Multiple patients with same
last name! // ogt
TECHNIQUE: AP portable, semi-upright chest radiograph.
COMPARISON: Chest radiographs ___.
FINDINGS:
Endotracheal tube is now positioned 3.3 cm proximal to the carina. Enteric
tube is seen with the side-port probably above the gastroesophageal junction
and advancement by approximately 9 cm is recommended. A right-sided
Port-A-Cath is unchanged. Cardiomediastinal silhouette is unchanged.
Re-demonstration of a hazy opacity at the right lung base. No large pleural
effusion or pneumothorax. Lucent appearance of the lung apices is exaggerated
by position. No acute osseous abnormalities.
IMPRESSION:
1. Enteric tube side port is likely above the gastroesophageal junction and
advancement by approximately 9 cm is recommended.
2. Endotracheal tube is appropriately positioned.
3. Persistent right basilar airspace opacity.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS
INDICATION: ___ year old woman with og tube // og tube placement
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph of the chest performed 5 days prior.
FINDINGS:
Enteric tube extends below the diaphragm with the tip in the body of the
stomach. Heart size is normal. Mild pulmonary vascular congestion is
unchanged compared to the prior exam. New opacities are seen at the right
lung base. No evidence of pneumothorax. No large pleural effusion.
IMPRESSION:
-Interval advancement of the enteric tube, which now terminates within the
body the stomach.
-New opacities within the right lung base could be seen in setting of
infection/aspiration.
-Persistent mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated bilirubin, encephalopathy. //
any liver or gall bladder pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is a 5 mm calcified
granuloma; otherwise, there is no focal liver mass. The main portal vein is
patent with hepatofugal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 8.0 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 9.9 cm
Left kidney: 11.4 cm
OTHER: The visualized portions of aorta and IVC are within normal limits.
There is reversal of flow in the splenic vein. There are multiple splenorenal
collaterals.
IMPRESSION:
1. Cirrhotic liver. No focal suspicious hepatic mass is identified.
2. Sequelae of portal hypertension including reversal of flow in the main
portal vein (hepatofugal) and splenic vein and present splenorenal
collaterals.
3. Cholelithiasis without sonographic evidence of cholecystitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS in setting of hepatic encephalopathy -
intubated for airway protection. OGT replaced // OGT placement
TECHNIQUE: Portable chest AP
COMPARISON: Multiple prior chest radiographs, most recent radiograph obtained
hours prior
FINDINGS:
Endotracheal tube is about 1.7 cm above the carina. Nasogastric tube
terminates in the stomach. Right Port-A-Cath tip terminates in the cavoatrial
junction.
In comparison to the radiograph obtained 9 hours prior, the mild pulmonary
vascular congestion is unchanged. Opacification at the right lower lung base
is unchanged. No large pleural effusions. No pneumothorax.
IMPRESSION:
1. Nasogastric tube terminates in the stomach.
2. Unchanged mild pulmonary vascular congestion.
3. Unchanged right lower lobe opacity, which may be secondary to infection or
aspiration.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Respiratory distress
Diagnosed with Altered mental status, unspecified
temperature: 97.1
heartrate: 97.0
resprate: 32.0
o2sat: 97.0
sbp: 110.0
dbp: nan
level of pain: UTA
level of acuity: 1.0 | SUMMARY:
====================
Ms. ___ is a ___ history of EtOH cirrhosis previously
decompensated by recurrent HE, metastatic squamous cell
esophageal carcinoma w/ no current plan to start chemo/XRT,
previous breast CA s/p L breast mastectomy, HFrEF 40%, admitted
for hepatic encephalopathy and aspiration pna requiring
intubation, treated with lactulose/rifaximin and antibiotics for
pneumonia, s/p extubation and resolution of altered mental
status.
TRANSITIONAL ISSUES
=====================
[ ] discharged on Augmentin for treatment of aspiration pna, to
be completed ___ AM
[ ] PPI was started in setting of acute on chronic anemia and
melena, discontinued at discharge - consider restarting as
outpatient if needed
[ ] ASA held at time of discharge d/t reports of melena and
acute on chronic anemia - consider restarting as outpatient
(indication: secondary prevention)
[ ] Phosphorus was low towards the end of hospitalization -
recommend rechecking on ___
[ ] Sodium bicarb increased from home regimen given ongoing
acidosis - recommend titrating prn and rechecking chemistry
___
[ ] prescribed lorazepam for nausea, anxiety, insomnia -
consider discontinuing as outpatient given issues with
AMS/confusion
[ ] patient to call to schedule Oncology appointment after
discharge.
NEW MEDICATIONS: Augmentin (ends ___ AM)
CHANGED MEDICATIONS: Sodium Bicarbonate, Thiamine
HELD MEDICATIONS: ASA
ACUTE ISSUES
=============
#Hepatic Encephalopathy
#EtOH cirrhosis, Child C
Patient with history of EtOH cirrhosis with ongoing EtOH intake
decompensated by frequent acute HE in setting of lactulose
non-adherence who presents with AMS. Likely trigger is lactulose
noncompliance and resulting HE. Infectious workup has been
negative except for possible aspiration pneumonia, SBP unlikely
given lack of tappable pocket on POCUS. Initial melena was self
limited and unlikely to have contributed to encephalopathy given
stable Hgb and vitals. Mental status improved with lactulose
administration and patient was extubated on ___. Pt was fully
alert and oriented without asterixis for few days prior to
discharge.
#Aspiration Pneumonia
Patient with new right basilar opacity on admission. Occurred
after arrival in ED. Most likely aspiration in setting of
altered mental status. Initially on vanc/ceftaz, transitioned to
augmentin. SLP consulted, passed with no aspiration events.
Sputum culture with no microorganisms, rare yeast. Discharged on
augmentin with plan for 7 day course, to be completed ___ AM.
# ___
Baseline creatinine 0.7. Cr up to 1.6 during admission, then
downtrended back to normal range with improved PO intake. Home
lisinopril was held during admission, restarted on day of
discharge.
#Hypernatremia
Na 150 on admission. likely iso of poor free water intake given
she has a history of ongoing EtOH intake with poor nutrition.
Worsening hypernatremia in the ICU to 159 likely iatrogenic iso
lactulose and large amount of stools. Corrected with D5W and Na
remained stable thereafter.
#Melena
#Acute on Chronic Anemia
Patient reportedly had melena on initial presentation. Did not
have melena or bloody stools during admission. Did have an acute
hgb drop ___ from 8 to 6.8 without overt signs of bleeding, s/p
1 U PRBC on ___ with appropriate response. Hgb then remained
stable for remainder of admission. Recent EGD in ___ with
esophageal mass but no varices. Started on PO PPI during
admission and home ASA held. Discontinued PPI on discharge as no
signs of bleeding.
#Lactic acidosis
Patient with uptrending lactate early in admission in setting of
being dry on
exam, likely poor PO intake as evidenced by hypernatremia.
Intubation likely led to hypotensive state, which probably
worsened an underlying hypovolemia. Resolved with IVF to normal
range.
#Metabolic acidosis
#Respiratory alkalosis
Has baseline mixed acid base disturbance with respiratory
alkalosis and metabolic acidosis. Chronically on sodium bicarb.
Home sodium bicarb was increased to 1300mg BID.
CHRONIC ISSUES
================
#HFrEF (EF 40%)
No ischemic work-up performed yet. Was seen outpt by cardiology
___ with plan to see her back in 6 weeks, repeat an echo at
that time and if the ejection fraction is not improved, consider
an ischemic evaluation. Has appointment scheduled ___ with
cardiology.
# Hypertension
Lisinopril held during admission iso ___. Restarted on day of
discharge.
#Metastatic squamous cell esophageal Ca
Found on recent EGD, during last admission had L supraclavicular
LN biopsy showing metastatic spread. Plan for chemo/XRT. Has had
port placed during last admission. Primary oncologist Dr. ___
was called by ICU team, discussed
no plans to pursue chemotherapy at this time. Patient will need
to call to schedule an appointment after discharge.
#Breast CA
Dx ___ with cT4N0M0 disease, IDC, grade ___, ER/PR pos, HER-2
neg. Ki67 20%. Treated with intermittent neoadjuvant AI,
followed by lumpectomy (positive margins) and completion
mastectomy. Final pathology ypT2Nx, grade ___, ER/PR pos, HER-2
neg. Was on adjuvant anastrozole for some period of time but
stopped about a year ago. Was followed at ___ by Dr ___
___ oncology) and Dr ___ oncology), but
spotty follow-up, last med onc visit in ___. Unclear how long
she was on AI.
#HX of CVA
Old ischemia on CT head. Statin was continued at time of
discharge for stroke prevention, however ASA was held iso melena
and acute on chronic anemia this admission. Consider
risk/benefits of ASA as outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin / Flagyl
/ doxycycline / niacin
Attending: ___.
Chief Complaint:
worsening R sided weakness and slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ RH woman with a history of HTN, HL, DM
type II, prior L periventricular lacunar stroke, obesity,
migraines, depression/anxiety who presents with worsening R
sided
weakness and slurred speech. On initial exam she was extremely
anxious and tearful and is a very difficult and inconsistent
historian. Her speech is a bit bizarre, broken and stuttering
("Woke up. 12:30. Had stroke. Leg weak.") but at times she is
able to produce fluent sentences and complex words ("lacunar
stroke") as well. There was no dysarthria. She reports that she
went to sleep around 4am feeling in her usual state of health.
She woke up around 12:30 to go to the bathroom. She was able to
walk to the bathroom but noticed that she was dragging her R
leg.
She initially says this was new but then says she has had this
since her prior stroke but it may have been worse. She then went
back to sleep for 2 hours and woke up around 2:30pm. She tried
to
stand and felt that her R leg weakness was even worse than
before. She says her entire R side felt numb as well (also
unclear whether new or old). She became very anxious that she
was
having another stroke and called her PCP's office. She says her
speech also became slurred around this time. Per PCP ___ (at
4:35pm) she had called reporting R sided weakness and numbness
and confusion, but no changes in her speech were noted at that
time. She was advised to go to the ED by ambulance but she
refused and called her PCA, who arrived at her apartment around
5pm. Her PCA reported that her speech was slurred upon her
arrival. She was able to walk to her car with assistance (though
says she was dragging her R leg) and was driven to the ED.
Upon arrival at 5:45pm a code stroke was called. Initial NIHSS
was 9, although her exam was quite variable with inconsistent
effort and give-way weakness in the R arm and leg, and her
speech
alternated between broken/stuttering and fluent. CT head showed
a
possible hypodensity in the R pons although difficult to
distinguish from possible artifact. CTA and CTP were normal.
Upon repeat examination after she returned from CT she had
calmed
down and her exam had improved quite a bit. She initially was
still speaking in short, broken phrases but then quickly became
fluent and normal without dysarthria. The strength in her R arm
and leg also improved but continued to fluctuate, at times able
to hold her arm up against gravity for a few seconds and at
others not moving it at all.
She reports that she has been undergoing ___ and OT since her
stroke ___ years ago and walks with a walker at baseline. Of
note she has presented to the ED in the past ___ and ___
per our records) with complaints of worsened R sided weakness
but
has been found to have no evidence of organic weakness on exam.
She reports these episodes as additional strokes and says she
has
now had a total of 4 strokes. She is very frustrated by this and
says every time she seems to be doing better with ___ she has
"another stroke" and gets weaker again.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Reports abdominal pain since an
endoscopy 2 weeks ago for which she was supposed to see her
doctor tomorrow. She also reports R jaw pain since this
afternoon. Denies nausea, vomiting, recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
PMH:
- stroke in L periventricular region - occurred at age ___ per
pt,
left with residual R sided weakness/numbness
- seizure disorder
- migraine
- obesity
- depression (with SI/A)
- GERD
- IBS
- HTN
- HLD
- DM II
- tonsillectomy
- L acromioplasty
Social History:
___
Family History:
negative for seizure, stroke, migraine
Physical Exam:
Physical Exam on admission:
Vitals: 97 181/95 18 100%
General: Awake and alert, tearful and extremely anxious
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic, regular rhythm, nl. S1S2, no M/R/G noted
Abdomen: soft, diffusely tender to palpation, normoactive bowel
sounds, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: On initial exam she is extremely anxious and
tearful and shaking uncontrollably. Her speech was initially
somewhat odd - broken/stuttering but not dysarthric ("Leg weak.
Had stroke. Take Plavix. Jaw hurt. Need bedpan.") but once her
anxiety improved her speech immediately became fluent and back
to
normal. She is alert, oriented to self, month, year, and ___
but not date. Knows president and Republican candidate in
upcoming election. Attentive, able to name ___ backward except
skips ___. Naming intact for all objects on stroke card (except
called hammock a swing). Able to read without difficulty. Speech
was not dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Reports decreased sensation to light touch, pinprick, and
cold
sensation over R V1-V3 distribution. Vibration splits midline.
VII: Slight R lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
+Coarse action tremor b/l (reports this is chronic).
Strength ___ throughout in all muscle groups in L upper and
lower
extremity.
Initially she is not moving the R arm and leg at all except for
a
flicker of movement in her fingers and toes. Later after her
anxiety improves she moves a bit more spontaneously but still
does not lift her arm or leg anti-gravity. When her arm is
lifted
she holds it against gravity for a second and then lets it fall.
She pushes with full strength in her triceps briefly, and has at
least ___ strength in biceps, wrist extensors, finger
extensors, and finger flexors but gives way almost immediately.
Similarly she does not lift her leg anti-gravity but when her
knee is placed in a flexed position she is able to briefly hold
it there before letting it fall. She has give-way weakness in
hamstring and quadriceps, gives no effort at TA, and has at
least
4+/5 strength in gastroc.
-Sensory: Reports decreased sensation to all modalities over R
face, arm, and leg.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: +Coarse action tremor b/l with any movement,
somewhat variable. No dysmetria on L FNF, unable to test on R.
-Gait: Deferred as she refused to stand without her walker
On discharge:
VSS
NAD, comfortable
Breathing nonlabored
Alert & fully oriented, appropriately conversant with intact
fluency/articulation/prosody/comprehension
Motor exam still complicated by inconsistent effort and
significant give-way weakness. Hoover sign positive. Adductor
sign positive.
Gait was observed: with walker, pt is able to walk comfortably
if slowly. Good weightbearing on right leg.
Pertinent Results:
___ 07:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 07:25PM URINE RBC-2 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:53PM GLUCOSE-180* NA+-140 K+-3.9 CL--99 TCO2-27
___ 05:50PM UREA N-13
___ 05:50PM WBC-4.7 RBC-4.67 HGB-14.8 HCT-45.3 MCV-97
MCH-31.7 MCHC-32.7 RDW-12.4
___ 05:50PM PLT COUNT-209
___ 05:50PM ___ PTT-32.1 ___
___ 05:57AM CREAT-0.6
CXR ___
FINDINGS: AP upright and lateral views of the chest are
provided. The lungs
appear clear. The heart is borderline enlarged. Mediastinal
contour is
normal. No effusion or pneumothorax. Bony structures are
intact.
IMPRESSION: Borderline cardiomegaly. Otherwise, normal
EEG ___ prelim read: spike and wave, poly-spike and wave
discharges triggered by photo stimulation, indicate primary
generalized epilepsy.
MRI brain ___ neurology chief read: evidence of previously seen
left corona radiata/internal capsule lacune. No new stroke.
Medications on Admission:
Meds:
- plavix 75 mg po daily
- depakote ER 500 mg po tid
- tegretol XR 400 mg po tid
- clonazepam 1 mg po bid
- citalopram 20 mg po daily
- pantoprazole 40 mg po daily
- vit D 2 50,000 u po weekly
- rosovustatin 20 mg daily
- lisinopril 10 mg daily
- dicyclomine 10mg TID
- fluticasone 2 sprays BID
- albuterol ___ puffs Q4-6hrs prn
- tylenol ___ prn
- multivitamin
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Divalproex (EXTended Release) 500 mg PO TID
3. Carbamazepine (Extended-Release) 400 mg PO TID
4. Clonazepam 1 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. DiCYCLOmine 10 mg PO TID:PRN stomach cramps
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
13. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
14. Multivitamins 1 TAB PO DAILY
15. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
___:
unspecified late effects of cerebrovascular disease
Right hemiparesis
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: ___ female with acute onset of abnormal speech, who
presents for evaluation of stroke.
COMPARISONS: Head CT from ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, helically-acquired axial images were
obtained through the head and neck using a CTA protocol after the uneventful
administration of 110 cc of Omnipaque intravenous contrast. Curved reformats,
volume-rendered reformations, and CTA maximum intensity projection images were
generated on an independent workstation. In addition, CT perfusion was
performed with blood flow, blood volume, and mean transit time maps created on
an independent workstation.
FINDINGS:
NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, edema, masses, mass
effect, or acute infarction. There is a slight deformity of the left lateral
ventricle with a slight hypodensity in the left corona radiata, most likely
secondary to an old infarct (2;19). The ventricles and sulci are normal in
size and configuration. No fracture is identified. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
CT PERFUSION: The perfusion maps appear normal with no evidence of delayed
transit time, reduced blood flow or volume.
HEAD AND NECK CTA: The Circle of ___ is patent. Of note, there is a
left-sided fetal PCA. The vertebral arteries are patent without evidence of
stenosis. The carotid arteries bilaterally are patent and demonstrate no
stenosis per NASCET criteria. There are atherosclerotic mural calcification
of the cavernous portion of the internal carotid arteries bilaterally as well
as atherosclerosis at the right carotid bifurcation. There is no evidence of
aneurysm formation or other vascular abnormality.
CONCLUSION:
1. No evidence of hemorrhage, mass effect, or acute infarction.
2. Patent Circle of ___. Patent carotid and vertebral arteries and their
major branches without evidence of stenosis. No evidence of aneurysm
formation or other vascular abnormality.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Worsening neuro symptoms, question pneumonia.
FINDINGS: AP upright and lateral views of the chest are provided. The lungs
appear clear. The heart is borderline enlarged. Mediastinal contour is
normal. No effusion or pneumothorax. Bony structures are intact.
IMPRESSION: Borderline cardiomegaly. Otherwise, normal.
Radiology Report
INDICATION: ___ woman with a history of prior left corona radiata
lacunar stroke who presents for worsening right-sided weakness and speech
changes.
COMPARISON: CTA, CTP from ___.
TECHNIQUE: Routine ___ enhanced non-contrast MR examination with axial SE
and axial FLAIR, with coronal and sagittal reformations.
FINDINGS:
Again seen is the left corona radiata lacunar stroke. There is no evidence of
new infarction or of hemorrhage. No abnormal fluid collections are present.
The ventricles and sulci are normal in size and configuration. No diffusion
abnormality is detected. No intracranial masses identified. The major
intracranial vessel flow voids are preserved.
The brainstem, posterior fossa and cervicomedullary junction are preserved.
The orbits, periorbital and paracavernous spaces are normal. No abnormality
of the skull base or calvaria is identified.
IMPRESSION:
1. No evidence of masses, or hemorrhage or new infarction.
2. Again seen is the old lacunar infarct in the left corona radiata.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CODE STROKE
Diagnosed with OTHER SPEECH DISTURBANCE, MUSCSKEL SYMPT LIMB NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ RH woman with a history of HTN, HL, DM type II,
prior L periventricular lacunar stroke, obesity, migraines,
depression/anxiety who presents with a somewhat unclear history
of worsening R sided weakness and slurred speech. Initial exam
was limited by extreme anxiety/tearfulness and significant
variability. This morning, again effort-dependent weakness.
No evidence for new stroke on CT head or MRI; only stroke is the
original corona radiata lacune ___ years ago.
EEG redemonstrates generalized epilepsy (spike and wave,
poly-spike and wave discharges triggered by photo stimulation)
Levels of anticonvulsants within range.
With encouragement, pt was able to use her leg fully and bear
weight when walking, although she continues to complain of
inability to move it when lying in bed. In light of her
significant functional overlay and embellishment, it is doubtful
whether her symptoms should be characterized as a true
recrudescence of her former stroke symptoms; more likely, they
represent an acute stress neurosis. There is no evidence for a
new cerebral insult like a stroke. Although she has generalized
epilepsy, her presentation is not consistent with a focal
seizure and ___ paralysis.
Stroke risk factors were assessed; pt's HBA1c is 5.9, lipid
panel is still pending.
Pt should continue with physical therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / vancomycin /
levofloxacin / acyclovir / Lipitor / lisinopril / amlodipine
Attending: ___.
Chief Complaint:
abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with history of DVT and PE on
coumadin, T2DM, HTN, large smoking history, Crohn's, multiple
SBOs and abdominal surgeries who presents with right side
abdominal pain and diarrhea. 2 weeks prior to admission Mr.
___ was in his usual state of health when he began
experiencing watery diarrhea ___ times per day which consisted
mostly of water with small pieces of stool as well as what he
describes as "rectal pain" and diffuse pain across his entire
abdomen. His watery diarrhea continued when 4 days prior to
admission he began noticing bright red blood on the toilet
tissue and occasional blood mixed in with his stool. 2 days
prior to admission, Mr. ___ developed sharp episodic
non-radiating right side abdominal pain which came every ___
minutes then gradually dissipated. Of note, he admits to
experiencing nightsweats, increased satiety, increased belching
and increased flatulence for the past 2 weeks, and 50lb weight
loss over the past year. He also notes one episode of hematuria
2 weeks ago with the onset of his symptoms, rhinorrhea, and
increased urinary frequency of late which is consistent with his
past UTIs. He denies any fever, chills, vomiting, sick contacts,
recent travel, change in diet, change in his pain with eating,
dysuria, shortness of breath, or chest pain. Also of note, Mr.
___ had 7 sessile polyps removed during colonoscopy on
___, and was found to have multiple colonic diverticula at
this time. On ___ multiple biopsies were taken without any
evidence of colitis.
In the ED, initial vitals were: 98.7 74 145/99 18 100%
ED Labs: significant for INR 2.6, lipase 108, CRP 2.1, positive
UA
ED Studies:
CT Abdomen and pelvis with contrast - showed no acute
intraabdominal process, small bowel containing hernia adjacing
to surgical scarring in the RLQ without evidence of obstruction
UA - Lg leuk, 68 WBC, few bacteria, trace protein
ED Course: The patient was given morphine 5mg x1 and zofran 4mg
x1. He was admitted for further workup of abdmominal pain and
bloody diarrhea.
Vitals prior to transfer were: 98.9 69 125/66 17 100% RA.
Upon transfer, Mr. ___ continued to complain of R sided
abdominal pain.
Past Medical History:
-Diabetes mellitus with renal manifestation
-Hyperlipidemia
-Colon adenomas
-Hypertension, essential, benign
-PANIC DISORDER W/O AGORAPHOBIA
-DEPRESSIVE DISORDER
-Pulmonary nodule/lesion, solitary
-Crohn's disease
-NEUROPATHY, UNSPEC
-History of pulmonary embolism
-Coronary artery disease
-History of obesity
-COPD, moderate
-___ disease
-CKD (chronic kidney disease) stage 1, GFR 90 ml/min or greater
-PUD c/b perforation, s/p laparotomy, colostomy and reversal
-multiple hernia surgeries
-open cholecystectomy
Social History:
___
Family History:
No family GI history
Father - had emphysema
Mother - had CAD, PVD, and RA
Sister - had TTP
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.8 BP 112/58 HR 58 RR 18 Sat 96%RA Wt 74.7kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of
erythema and exudate
Neck: supple, no LAD or masses.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, Moderately tender at border
between RUQ and RLQ. Bowel sounds present in all quadrants, no
rebound tenderness or guarding. Multiple large ~1cm external
hemorrhoids and erythema on rectal exam.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry. Normal texure and temperature. Few echymmoses on
right wrist.
Neuro: CN II-XII intact. Full ___ strength in UE and ___
bilaterally. Sensation to light touch grossly intact in face,
UE, and ___ bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.5 Tc 98.3 BP 127/60 (106-130/45-60) HR 68 (55-68)
RR 20 Sat 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of
erythema and exudate
Neck: supple, no LAD or masses.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, Moderately tender at border
between RUQ and RLQ. Bowel sounds present in all quadrants, no
rebound tenderness or guarding. Multiple large ~1cm external
hemorrhoids and erythema on rectal exam.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Dry. Normal texure and temperature. Few echymmoses on
right wrist.
Neuro: CN II-XII intact. Full ___ strength in UE and ___
bilaterally. Sensation to light touch grossly intact in face,
UE, and ___ bilaterally.
Pertinent Results:
ADMISSION LABS
___ 04:20PM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 04:20PM WBC-9.8 RBC-5.31 HGB-11.2* HCT-37.9* MCV-71*
MCH-21.1* MCHC-29.6* RDW-18.4* RDWSD-44.9
___ 04:20PM PLT COUNT-231
___ 04:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:20PM URINE RBC-0 WBC-68* BACTERIA-FEW YEAST-NONE
EPI-1
MICROBIOLOGY
___ Blood cx pending
Urine culture
___ 4:39 pm URINE Site: NOT SPECIFIED
ADDED TO CHEM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS
___ 05:43AM BLOOD WBC-6.5 RBC-4.80 Hgb-10.1* Hct-34.2*
MCV-71* MCH-21.0* MCHC-29.5* RDW-18.0* RDWSD-44.7 Plt ___
___ 05:43AM BLOOD ___ PTT-38.6* ___
___ 05:43AM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-142
K-4.0 Cl-106 HCO3-27 AnGap-13
___ 05:43AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. GlipiZIDE 10 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Warfarin 3 mg PO DAILY16
8. Rosuvastatin Calcium 20 mg PO QPM
9. TraZODone 100 mg PO DAILY
10. Lorazepam 1 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lorazepam 1 mg PO Q6H:PRN anxiety
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Rosuvastatin Calcium 20 mg PO QPM
7. Warfarin 3 mg PO DAILY16
8. Acetaminophen 1000 mg PO Q8H:PRN abdominal pain
RX *acetaminophen [Pain Reliever] 500 mg 2 capsule(s) by mouth
every 8 hours Disp #*30 Capsule Refills:*0
9. Cefpodoxime Proxetil 400 mg PO Q12H
Last dose should be administered ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
10. GlipiZIDE 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. TraZODone 100 mg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
RX *ferrous gluconate 324 mg (37.5 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
14. Outpatient Lab Work
ICD9: V12.51
Please check INR ___.
Please fax results to:
___, RN - ___
Please fax results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea
Bleeding Hemorrhoids
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abd pain, evaluate for small bowel obstruction, abscess,
or UC flare.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Total DLP (Body) = 686 mGy-cm.
IV Contrast: 130 mL Omnipaque
COMPARISON: Prior CT of the abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent. Mild
prominence of the CBD is likely related to cholecystectomy.
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. A 2.5 cm
simple cyst arises from the lower pole of the left kidney. Scattered renal
hypodensities bilaterally are too small to fully characterize but likely
represent additional simple cysts. 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. Colon and rectum are within normal limits.
Appendix contains air, has normal caliber without evidence of fat stranding.
There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is heavy calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome osseous lesions. A small bowel containing
hernia is noted in the anterior lower right abdominal wall (2:78) without
evidence of upstream obstruction. Overall appearance is similar to the prior
study from ___.
IMPRESSION:
1. No acute intra-abdominal process.
2. Small bowel containing hernia adjacent to an area of surgical scarring in
the right lower quadrant without evidence of obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Diarrhea
Diagnosed with ABDOMINAL PAIN RLQ, DIARRHEA, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.7
heartrate: 74.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 99.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ year old man with history of DVT and PE on
coumadin, T2DM, HTN, large smoking history, Crohn's, multiple
SBOs and abdominal surgeries who presented with right side
abdominal pain and diarrhea.
#Abdominal pain and diarrhea/brbpr: Likely secondary to external
hemorrhoids and infectious enteritis. Mr. ___ reported
sharp episodic non-radiating right side abdominal pain which
came every ___ minutes then gradually dissipated before
returning again. He had one loose, non-bloody bowel movement
while in the ED but had no diarrhea during his hospitalization
despite reporting a two week history of watery, non-bloody bowel
movements ___ times per day which became tinged with blood 4
days prior to admission. CRP was wnl, CT A/P showed a hernia
containing bowel but was negative for fat stranding, mesenteric
lymphadenopathy, and bowel obstruction. Rectal exam revealed
multiple large external hemorrhoids. He was given Tylenol for
pain and tolerated a clear liquids diet. He was started on a
topical hydrocortisone BID for external hemorrhoids. He was
evaluated by the surgical team given his hx of multiple
abdominal surgeries and hernia, however no surgical intervention
was advised.
#Complicated Urinary Tract Infection: On admission Mr. ___
reported increased urinary frequency consistent with past UTIs.
UA done in the ED was positive, so he was started on a 7 day
course of Ceftriaxone 1g IV in the ED, and completed ___ days of
the course during his hospital stay. Urine culture grew
pan-sensitive E. coli. He was switched to PO Cefpodoxime for
continuation of the remaining 5 days of this antibiotic course
upon discharge. Given his history of multiple UTIs, Mr.
___ complicated UTI was believed to be secondary to
urinary tract structural abnormality vs. prostatic enlargement.
#Microcytic Anemia: Mr. ___ had low H/H with low MCV in
the ED that persisted throughout his hospital stay. Iron studies
showed iron deficiency anemia. He was started on Ferrous
gluconate 324mg daily. His microcytic anemia was believed to be
secondary to chronic bleeding from hemorrhoids vs. nutritional
deficiency. Slow bleeding from occult GI malignancy is also
possible.
#Hypomagnesemia: On admission Mr. ___ was found to have
low magnesium. He was given Magnesium Oxide, after which his
magnesium level normalized. This hypomagnesemia was believed to
be secondary to diarrhea in the setting of infectious enteritis
vs. colitis.
#Weight loss/Fe deficiency anemia: Mr. ___ reported
unintentional 50lb weight loss over the past year. PSA sent on
admission was within normal limits. Serum TSH level was sent as
further workup of his weight loss, and will be followed up after
discharge. Further workup for malignancy should be considered in
the outpatient setting.
#T2DM: Mr. ___ was started on Humalog sliding scale upon
admission. His blood glucose remained stable throughout the
admission. He will be restarted on his diabetes regimen of
Glipizide and Metformin upon discharge.
#History of PE and DVT: Mr. ___ was continued on his home
dose of warfarin during his hospitalization and his INR remained
therapeutic. He should continue this warfarin dosage after
discharge, with periodic f/u by PCP to test INR.
#Coronary artery disease: Mr. ___ was continued on his
home dosages of ASA and
Rosuvastatin during this hospitalization given his history of
coronary artery disease.
#Peptic Ulcer Disease: Continued on his home dosage of
Omeprazole during this hospitalization given his history of
peptic ulcer disease.
#HTN: Continued on his home dosage of Metoprolol tartrate for
HTN during this hospitalization with good blood pressure
control.
#HLD: Continued on his home dosage of Rosuvastatin during this
hospitalization.
#Insomnia: Continued on his home dosage of Trazodone for
insomnia during this hospitalization.
#Panic Disorder with Agoraphobia: Continued on his home dosage
of Lorazepam PRN for panic disorder during this hospitalization.
He did not require any administrations of the Lorazepam during
his stay.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of T1D on Humalog insulin pump (followed by
Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2
weeks ago without residual deficits who is admitted for DKA.
He reports that his blood sugar has been under good control
today (low 200s) until this morning when he noted it to be 220
prior to breakfast. He then went out to eat and when he
returned noted his glucose to be in the 500s. He set his pump
to deliver additional insulin boluses and reports that he
received approximately 1500 units between 3pm and 9pm when he
presented to the ___. He typically receives a basal
infusion plus boluses of ___ for meals. He reports 3
episodes of NBNB vomiting, no fevers, chills, abdominal pain,
diarrhea, dysuria, or cough. No known sick contacts. He was
initially diagnosed with T1D in ___ and received an insulin
pump ___ years ago. His BG was initially very difficult to
control and he reports three prior episodes of DKA, last being
in ___ at which time he was thought to have a pump malfunction
and it was replaced.
At ___, he was found to have a BG in the 500s, Bicarb 11, and
anion gap 29 c/w DKA, with WBC of 17. CXR concerning for a
possible pneumonia and he was initiated on vanc/zosyn. He was
started on an insulin drip, given 2 L of fluids and transferred
here since no ICU beds available at ___.
The patient felt well on arrival to our ___. Denied any pain and
breathing comfortably. Clear lungs and normal heart sounds. Soft
and non-tender abdomen. Mild tachycardia (90s-100s) with stable
BPs 120-130s/40-50s, SaO2 94-96% RA.
He was continued on an insulin drip. ___ L NS administered.
Additional ___ L with K running at 250 per hour. Antibiotics
continued with Vanc and Zosyn.
Labs: WBC 17 -> 20.5, Bicarb 11 -> 8, Glucose 519 -> 425 ->
372,
Anion gap 29 - > 25, K 4.7.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
T1DM
Hypothyroid
Hypertension
Prior CVA
Social History:
___
Family History:
Not obtained
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 78, BP 134/59, O2 99% RA, BG 465
GEN: Well appearing
HEENT: No JVD
CV: RRR
RESP: CTAB
GI: Soft, non-tender, non-distended
MSK: No abnormalities
SKIN: WWP
NEURO: Mentating appropriately, neurologic exam grossly intact
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 807)
Temp: 97.6 (Tm 98.7), BP: 161/88 (139-181/63-92), HR: 64
(55-68), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA
GEN: Alert, NAD, appears comfortable
CV: RRR; no m/r/g
PULM: breathing comfortably, clear to auscultation bilaterally,
no wheezes, ronchi or crackles
NEURO: AAOx3, grossly intact, moving all 4 extremities
spontaneously and with purpose
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 01:20AM BLOOD WBC-20.5* RBC-4.74 Hgb-14.7 Hct-46.4
MCV-98 MCH-31.0 MCHC-31.7* RDW-13.8 RDWSD-49.8* Plt ___
___ 05:01AM BLOOD ___ PTT-26.5 ___
___ 01:20AM BLOOD Glucose-425* UreaN-30* Creat-1.4* Na-144
K-4.7 Cl-111* HCO3-8* AnGap-25*
___ 01:20AM BLOOD Phos-4.4 Mg-2.0
___ 03:25AM BLOOD Beta-OH-4.1*
___ 01:26AM BLOOD Glucose-419* Lactate-2.9* Na-138 K-4.1
Cl-115* calHCO3-9*
___ 03:25AM BLOOD ___ pO2-48* pCO2-20* pH-7.22*
calTCO2-9* Base XS--17
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
===========================
REPORTS AND IMAGING STUDIES
===========================
___
IMPRESSION:
Low lung volumes. No good evidence for cardiopulmonary
abnormality.
Although no acute or other chest wall lesion is seen,
conventional chest radiographs are not sufficient for detection
or characterization of most such abnormalities. If the
demonstration of trauma, or other osseous soft tissue
abnormality involving the chest wall is clinically warranted,
the location of any referable focal findings should be described
in the imaging request, clearly marked, and imaged with either
bone detail radiographs or Chest CT scanning.
============
MICROBIOLOGY
============
___ Blood Culture #1 =
___ Blood Culture #2 =
============================
DISCHARGE LABS
==============================
___ 04:43AM BLOOD WBC-9.6 RBC-4.72 Hgb-14.5 Hct-43.0 MCV-91
MCH-30.7 MCHC-33.7 RDW-13.4 RDWSD-45.1 Plt ___
___ 04:43AM BLOOD Plt ___
___ 04:43AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-144
K-4.0 Cl-108 HCO3-26 AnGap-10
___ 04:43AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. tadalafil 2.5 mg oral DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Glargine 28 Units Bedtime
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*1 Syringe
Refills:*0
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 5 Units QID per sliding scale 7 Units before LNCH; Units
QID per sliding scale 7 Units before DINR; Units QID per sliding
scale Disp #*1 Syringe Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY nasal
congestion
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. tadalafil 2.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
SVT
Hypertensive urgency
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 DKA, possible pulmonary edema// eval for
pulmonary edema
TECHNIQUE: Portable frontal chest radiograph
COMPARISON: None
FINDINGS:
Low lung volumes exaggerate the caliber and crowding vessels and make it
difficult to distinguish micro atelectasis at the lung bases from mild
interstitial edema, but heart size is normal and there is no pleural effusion
or other reason to suspect cardiac decompensation.
Slight leftward deviation of the lower cervical trachea may be a function low
lung volumes as well, but an enlarged right thyroid lobe can have the same
appearance.
No displaced rib fractures.
IMPRESSION:
Low lung volumes. No good evidence for cardiopulmonary abnormality.
Although no acute or other chest wall lesion is seen, conventional chest
radiographs are not sufficient for detection or characterization of most such
abnormalities. If the demonstration of trauma, or other osseous soft tissue
abnormality involving the chest wall is clinically warranted, the location of
any referable focal findings should be described in the imaging request,
clearly marked, and imaged with either bone detail radiographs or Chest CT
scanning.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, N/V, Transfer
Diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma
temperature: 98.4
heartrate: 106.0
resprate: 18.0
o2sat: 94.0
sbp: 131.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of T1D on
Humalog insulin pump (followed by Dr. ___ at ___, HTN,
hypothyroid, and recent stroke 2 weeks ago without residual
deficits who is admitted for DKA.
#Diabetic Ketoacidosis
Mr. ___ presented in DKA with anion gap of 25, serum glucose
of 425, elevated beta hydroxybuterate and a metabolic acidosis.
He was initiated on an insulin infusion, normal saline boluses,
and potassium and phosphate repletion. His gap rapidly closed
and his beta hydroxy-buterate trended to zero. His acidosis also
rapidly resolved. His insulin infusion was eventually weaned
down per protocol and when it reached 4u/hour we initiated
insulin subcutaneously with a initial basal dose of 28u
glargine, standing humalog of 3u per meal and a sliding scale.
He was able to eat at this time and he was then transferred to
the floor.
The etiology of his DKA was not immediately clear. He reports
multiple prior episodes. CXR did not reveal pneumonia and a UA
at an OSH did not show evidence of infection. His leukocytosis
was thought to be reactive. There was concern that his insulin
pump may have malfunctioned, though there was no clear evidence
this was the case. ___ endocrinology was consulted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
hypertension, headache, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ yo ___ and ___ speaking female
with a PMH of uncontrolled refractory HTN, Hepatitis C s/p
treatment, CKD V(cryoglobulinemia with MPGN), HFrEF d/t
infiltrative process (hx of LVEF 35%) who presented with a
headache and hypertension that started at 2 am last night.
Stated that she was in her usual state of health when she awoke
from bed with a pounding sensation in her head. SBP measured
215. Patient states often SBP is 190-200 with 160 being her
best. After waking last night, she noticed worsening swelling of
legs, felt palpitations, felt nauseous and had an episode of
vomiting. Stated that her vision was eventually became hazy.
Also noted chest tightness across the upper chest that did not
radiate. Patient felt short of breath and was breathing fast.
Also noted that she started to develop numbness in her hands and
legs beneath the knee. Was shaking periodically all over. Denied
every losing awareness of where she was or what was going on.
Denied any hx of panic attacks or increased stress in her life.
She felt weak and felt unsteady on her feet. Was brought to the
ED by her son.
In the ED, initial vitals were: 99.1 ___ 25 100%RA,
however BP was as high as 224/118.
Exam notable for tachypnea up to 34BPM, shaking in arms and legs
worse with intention. Motor ___ bilat.
Labs notable for:
___ 10:00AM BLOOD ___
___ 06:50AM BLOOD cTropnT-0.13*
___ 01:15PM BLOOD cTropnT-0.11*
___ 07:16AM BLOOD Lactate-2.6*
___ 09:07AM BLOOD Type-ART pO2-264* pCO2-9* pH-7.74*
calTCO2-13* Base XS--2
D-dimer 375
MB: 5
Negative urine tox screen. ECHO showed small pericardial
effusion with LVEF > 55%.
Imaging notable for CXR: Enlarged cardiac silhouette as on prior
without acute cardiopulmonary process. ECG without signs of
ischemia.
Patient was placed on supplemental O2, ?BiPAP for around an
hour, IV nitro drip, lorazepam 0.5mg and labetalol 800mg with
improvement in BP and resolution of symptoms.
Decision was made to admit for management of uncontrolled
hypertension. On transfer patient vitals: 62 146/79 18 100% RA
On the floor patient was comfortable and asymptomatic with
resolution of all her symptoms mentioned above. States that she
is adherent to her medications daily. At baseline she states she
is able to walk slowly up 3 flights of stairs before having to
rest, gets short of breath in the morning with activity but
improves throughout the day, has pillow orthopnea and paroxysmal
nocturnal dyspnea if lying flat. She feels like she is currently
at baseline. She does state that if her SBP is in the 120-130s
she feels lightheaded.
Past Medical History:
-HCV infection
-Cryoglobulinemia (derm & renal)
-Systolic CHF (EF 30%)
-Pericardial effusion and severe hypertension after ERCP in
___ to remove a CBD stone, c/b pancreatitis, c/p ileus
requiring exlap with LOA and reduction of internal hernia
-CKD Stage IV (baseline Cr around 2.5)
-Chronic anemia requiring transfusions
-Portal gastropathy
-s/p cholecystectomy
-Choledocholithiasis
Social History:
___
Family History:
No family history of liver disease. Reports history of HTN in
Mother and ___ Aunt. No history of CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.5 63 160/81 18 97RA
Gen: well developed, NAD, alert, cooperative.
HEENT: NC/AT, PERRLA, EOMI, non-icteric, MMM, no cervical
lymphadenopathy
CV: RRR, ___ systolic murmur, normal S1 and S2. JVP non-elevated
Pulm: normal respiratory effort, clear to auscultation
bilaterally
Abd: soft, non-tender, non-distended, NBS, no organomegaly
GU: deferred
Ext: warm well perfused. 2+ DP pulses bilat. Dark discoloration
of shins. No pedal edema.
Skin: warm and dry
Neuro: CNs grossly intact, ___ BLE and BUE strength. Sensation
to light tough intact. Normal gait. Finger to nose testing
normal. No tremors. No focal neurologic deficits.
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.5 63 144/80 18 99% RA
Gen: well developed, NAD, alert, cooperative.
HEENT: NC/AT, PERRLA, EOMI, non-icteric, MMM, no cervical
lymphadenopathy
CV: RRR, ___ systolic murmur, normal S1 and S2. JVP non-elevated
Pulm: normal respiratory effort, clear to auscultation
bilaterally
Abd: soft, non-tender, non-distended, NBS, no organomegaly
Ext: warm well perfused. 2+ DP pulses bilat. Dark discoloration
of shins. No pedal edema.
Skin: warm and dry
Neuro: CNs grossly intact, ___ BLE and BUE strength. Sensation
to light tough intact. Normal gait. Finger to nose testing
normal. No tremors. No focal neurologic deficits.
Pertinent Results:
ADMISSION LABS
==============
___ 06:50AM BLOOD WBC-7.6 RBC-3.42* Hgb-8.8* Hct-26.5*
MCV-78* MCH-25.7* MCHC-33.2 RDW-15.8* RDWSD-43.8 Plt ___
___ 06:50AM BLOOD Neuts-84.0* Lymphs-7.3* Monos-5.0 Eos-2.4
Baso-0.9 Im ___ AbsNeut-6.34*# AbsLymp-0.55* AbsMono-0.38
AbsEos-0.18 AbsBaso-0.07
___ 08:55AM BLOOD ___ PTT-32.5 ___
___ 06:50AM BLOOD Glucose-103* UreaN-73* Creat-3.9* Na-137
K-4.2 Cl-100 HCO3-15* AnGap-26*
___ 06:50AM BLOOD CK-MB-5
___ 06:50AM BLOOD cTropnT-0.13*
___ 10:00AM BLOOD ___
___ 01:15PM BLOOD cTropnT-0.11*
___ 06:50AM BLOOD Calcium-9.5 Phos-4.9* Mg-2.3
___ 08:55AM BLOOD D-Dimer-375
___ 06:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:42AM BLOOD ___ pO2-64* pCO2-10* pH-7.74*
calTCO2-14* Base XS--1 Intubat-NOT INTUBA
___ 07:16AM BLOOD Lactate-2.6*
DISCHARGE AND PERTINENT LABS
============================
___ 11:50AM BLOOD WBC-7.1 RBC-3.08* Hgb-7.8* Hct-25.1*
MCV-82 MCH-25.3* MCHC-31.1* RDW-16.2* RDWSD-48.3* Plt ___
___ 11:50AM BLOOD ___ PTT-40.8* ___
___ 11:50AM BLOOD Glucose-109* UreaN-72* Creat-4.5* Na-143
K-4.8 Cl-106 HCO3-24 AnGap-18
___ 11:50AM BLOOD ALT-7 AST-14 LD(LDH)-190 AlkPhos-87
TotBili-0.3
___ 11:50AM BLOOD Albumin-4.0 Calcium-9.1 Phos-6.2* Mg-2.6
Iron-PND
___ 11:50AM BLOOD Ferritn-PND TRF-PND
MICROBIOLOGY
============
___ 11:50 am IMMUNOLOGY
HCV VIRAL LOAD (Pending):
___ 10:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 8:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=======
___ CXR AP
FINDINGS:
The lungs are clear without focal consolidation edema, or
effusion noting that the left costophrenic angle is excluded
from the field of view. Cardiac silhouette is moderately
enlarged as on prior. Tortuosity of the descending thoracic
aorta is again noted.
IMPRESSION:
Enlarged cardiac silhouette as on prior without acute
cardiopulmonary process.
___ ECHOCARDIOGRAM
Conclusions
The left atrium is mildly dilated. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Severe LVH. Normal global and regional
biventricular systolic function. Small pericardial effusion
without tamponade physiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAzine 50 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. Doxazosin 8 mg PO HS
4. Labetalol 800 mg PO TID
5. Losartan Potassium 25 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Spironolactone 25 mg PO BID
8. Torsemide 40 mg PO DAILY
9. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Doxazosin 8 mg PO HS
RX *doxazosin 8 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. HydrALAzine 50 mg PO Q6H
RX *hydralazine 50 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
4. Labetalol 800 mg PO TID
RX *labetalol 200 mg 4 tablet(s) by mouth three times a day Disp
#*360 Tablet Refills:*0
5. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
TID w/ meals Disp #*90 Tablet Refills:*0
7. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Spironolactone 25 mg PO BID
RX *spironolactone 25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
10. Docusate Sodium 100 mg PO DAILY constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
11. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
12. Senna 17.2 mg PO QHS constipation
RX *sennosides [senna] 8.6 mg 2 capsules by mouth at bedtime
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Hypertensive Emergency
SECONDARY DIAGNOSES
===================
Hypertension
Congestive heart failure preserved ejection fraction
Chronic Kidney Disease (stage 5)
Anemia
Hepatitis
Pericardial Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dyspnea, tachypnea // evaluate for acute process
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear without focal consolidation edema, or effusion noting that
the left costophrenic angle is excluded from the field of view. Cardiac
silhouette is moderately enlarged as on prior. Tortuosity of the descending
thoracic aorta is again noted.
IMPRESSION:
Enlarged cardiac silhouette as on prior without acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Vomiting, Numbness, Headache
Diagnosed with Essential (primary) hypertension, Acute kidney failure, unspecified
temperature: 99.1
heartrate: 100.0
resprate: 25.0
o2sat: 100.0
sbp: 155.0
dbp: 117.0
level of pain: 8
level of acuity: 2.0 | Mrs. ___ is a ___ yo female with a PMH of uncontrolled
refractory HTN, Hepatitis C s/p Harvoni treatment, CKD
V(cryoglobulinemia with MPGN), HFrEF who presented with
hypertensive emergency with SBPs ~220/110.
#Hypertensive Emergency - Patient has a long history of
difficult to treat HTN with SBPs (180s-200). Stated that she is
compliant and never misses doses and uses a pillbox. Her
medications were changed last week by her nephrologist but she
hasn't updated her pillbox to reflect that change yet. Most
likely cause of her chronic hypertension is her history of
glomerulonephritis/renal disease. Outpatient extensive workup in
the past has been negative for secondary causes including
pheochromocytoma, renal artery stenosis, and hyperaldosteronism.
She did have a recent aldosterone checked that was normal and a
slightly elevated renin activity level most likely in the
setting of using an ___. On presentation to the ED, appeared to
be symptomatic from HTN including organ damage manifesting as
demand ischemia with troponin leak, ECG pattern with LVH and LV
strain. Also, felt dyspneic, was tachypnic with changes in
vision. Initially her ABG was notable for a pCO2 of 9 and pH of
7.74 These symptoms resolved with short duration of
nitroglycerin gtt, labetalol 800mg and lorazepam 0.5mg resulting
in improved BP control making other causes such as sepsis
unlikely. Tachypnea and pH normalized with improved BP control
to SBP 160s. Reversible posterior leukoencephalopathy syndrome
was unlikely as there were no changes in consciousness or mental
status. Patient's hand and feet numbness might actually have
been a tingling sensation from hyperventilation. On the floor
the patient was asymptomatic and was restarted on her
hypertensive medications. BP was maintained with SBPs in the
150's-160s night of admission then the next day with morning
medication administration was in the 130s-140s systolic. Given
that she had an unremarkable renal ultrasound in ___ for renal
artery stenosis and that her BP improved with home medication
dosing it is unlikely that it is a cause of her hypertension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vancomycin Analogues /
Gentamicin / Ciprofloxacin Hcl / Cefazolin / Benadryl /
Opioids-Morphine & Related
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
Patient had routine hemodialysis on ___ and ___
She also had ultrafiltration ___
History of Present Illness:
___ year old female with a past medical history notable for ESRD
on HD MWF s/p renal transplant x 3 (last in ___, RNY gastric
bypass, adrenal insufficiency, episodic hypoglycemia, anemia,
hepatitis C, hypertension, and PE ___ years ago, s/p 6 months of
warfarin) who presents with a 1 day history of dyspnea. She
denies a cough, sputum prodution or hemoptysis. She has not
experienced any fevers or chisll. Over all she has felt lousy
for 1 month. Over the last 3 days she has been limited by her
SOB which is worse with laying down. She denies chest pain. She
sleeps chronically with 4 pillows. She can now only walk a few
steps without getting short of breath. She denies PND. She has
no nausea or vomiting. A weight gain from 108 lbs in ___
to 123 on admission is noted. She says very little volume has
been removed at dialysis due to issues with hypoglycemia and
hypotension.
The patient was recently seen for a UTI on ___ and
prescribed Macrobid. She notes fatigue for the last 1 month and
sleeps only ___ hours per night. She recently received steroid
shots to her back several weeks prior to presentation.
In the ED intial vitals were: 98.8 59 169/78 16 100%
- Labs were significant for WBC 12.2 (87%), H/H 11.1/35.6, plt
252, INR 1.0, PTT 40.0, Na 137, K 4.8, Cl 101, HCO3 16, BUN 91,
Cr 8.6, glucose 391, Ca 7.4, Mg 2.0, P 3.3, BNP 10731, D-dimer
806, AG 20 and negative serum acetone. The patient is noted
noted to have a history of DMII prior to gastric bypass surgery,
most recent A1C 5.3 in ___.
- ECG showed no ischemic changes
- CXR showed no acute process, CTA w/o evidence of PE
- Patient was given IVFs and initial glcose in the 300s
decreased to 180s and anion gap decreased
- Renal was consulted and recommended regular dialysis
- VBG: pH 7.41, pCO2 32, pO2 52, HCO3 21, glu 180
- Repeat chem 7: Na 140, K 4.9, Cl 103, HCO3 19, BUN 96, Cr
9.3, AG 18
- The patient was admitted to medicine for further workup of
hyperglycemia
Vitals prior to transfer were: 98.3 53 157/68 16 100% RA
On the floor the patient's breathing is not improved. She
complained of feeling tired. She reports gaining weight and low
volume fluid removal at dialysis.
Past Medical History:
- ESRD due to RPGN on HD on MWF. Patient is s/p renal transplant
x3 (LRRT in ___ and DCD in ___ and ___ chronic allograft
nephropathy
- S/p gastric bypass surgery complicated by
leak/peritonitis/sepsis
- DMII prior to bypass surgery
- Recurrent UTI with resistant E. coli and Klebsiella
- Adrenal insufficiency
- Hypertension
- Pancreatic insufficiency
- Autonomic dysfunction w/ orthostasis
- Pulmonary embolism in ___ s/p 6 months of warfarin
- Hepaitis C secondary to blood transfusions
- Neuropathic foot pain bilaterally (unclear etiology)
- Spina bifida occulta
- Gastroesophageal reflux
- Anemia of chronic disease
- Chronic tension headaches
- Osteopenia
- S/p ventral hernia repair
- S/p partial excision of RUE and LUE AV-graft
- S/p parathyroidectomy
- S/p appendectomy
- S/p bilateral tubal ligation,
- S/p abdominoplasty
- S/p bilateral breast reduction,
Social History:
___
Family History:
Her brother has a history of kidney disease secondary to
hypertension. Father with lung cancer. Maternal grandmother with
colon cancer and stroke. Siblings with HTN, DM2, ESRD, and
hypothyroidism.
Physical Exam:
ADMISSION EXAM:
Vitals- 98.6 162/74 59 20 100% RA
General- middle aged AA female in NAD, noticeable
fatigue/malaise
HEENT- PERRL, conjunctiva normal, nose clear, OP w/o lesions,
MM moist
Neck- supple, no LAD, JVD at ___
Lungs- clear to auscultation, no W/R/R
CV- RRR, S1/S2 normal, soft systolic murmur at base, normal PMI
Abdomen- +BS, soft, non-distended, mild tenderness on the
right, no rebound or guarding
GU- not performed
Ext- WWP, trace lower extremity edema in thighs, no
clubbing/cyanosis
Neuro- CNII-XII intact, good stregth in all extremities with
poor effort
Skin- occasional bruises
DISCHARGE EXAM:
Vitals- 98.0, 107/62 (107-146/62-89), 69, 18, 100% RA
Blood sugars: 407 post-dinner (given 3 units Humalog) -> 137 2
hours later -> 101 at midnight -> 78 at 0600
General: NAD, alert, oriented, eating breakfast
Lungs: CTAB, no w/r/r
CV: RRR, ___ SEM at base
Abd: Soft, mildly tender to palpation over transplanted kidney
Ext: WWP, no ___ edema, tender left lateral foot with palpable
bone spur
Pertinent Results:
ADMISSION LABS
___ 04:49PM BLOOD WBC-12.2* RBC-3.59* Hgb-11.1* Hct-35.6*
MCV-99* MCH-30.9 MCHC-31.2 RDW-14.7 Plt ___
___ 04:49PM BLOOD Neuts-87.4* Lymphs-9.9* Monos-2.0 Eos-0.6
Baso-0.1
___ 04:49PM BLOOD ___ PTT-40.0* ___
___ 04:49PM BLOOD Glucose-391* UreaN-91* Creat-8.6*# Na-137
K-4.8 Cl-101 HCO3-16* AnGap-25*
___ 09:30PM BLOOD ALT-42* AST-42* AlkPhos-99 TotBili-0.2
___ 04:49PM BLOOD ___
___ 04:49PM BLOOD Calcium-7.4* Phos-3.3 Mg-2.0
___ 07:01PM BLOOD D-Dimer-806*
___ 09:30PM BLOOD Acetone-NEGATIVE
___ 09:44PM BLOOD ___ pO2-52* pCO2-32* pH-7.41
calTCO2-21 Base XS--2 Intubat-NOT INTUBA
___ 09:44PM BLOOD Glucose-180*
PERTINENT LABS
___ 12:38AM BLOOD %HbA1c-6.1* eAG-128*
DISCHARGE LABS
___ 07:00AM BLOOD WBC-13.6* RBC-3.63* Hgb-11.4* Hct-35.5*
MCV-98 MCH-31.5 MCHC-32.2 RDW-14.5 Plt ___
___ 07:00AM BLOOD Glucose-225* UreaN-88* Creat-8.7* Na-137
K-4.3 Cl-98 HCO3-21* AnGap-22*
___ 07:00AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0
MICRO
HCV VIRAL LOAD (Final ___: 1,730,405 IU/mL.
IMAGING
CXR: No acute cardiopulmonary process. No evidence of pulmonary
edema.
CTA CHEST:
1. No evidence of pulmonary embolism. No other acute findings
identified.
2. Mild bibasilar atelectasis/scarring.
RENAL TRANSPLANT ULTRASOUND:
Globally decreased blood flow to the renal transplant, with
probably markedly elevated resistive indices.
LEFT FOOT X-RAY:
No evidence of acute fracture or dislocation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Calcium Carbonate 1000 mg PO BID
4. Calcium Carbonate ___ mg PO QHD
5. Calcium Carbonate 1500 mg PO DAILY
6. ClonazePAM 0.5 mg PO QHS:PRN insomnia
7. Omeprazole 20 mg PO DAILY
8. Dialyvite (B complex-vitamin C-folic acid;<br>vit B cplx
___ ___ mg-mg-mcg-mg oral daily
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Gabapentin 100 mg PO DAILY:PRN leg pain
11. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Glucagon 1 mg IM Q15MIN:PRN blood sugar less than 50
RX *glucagon (human recombinant) [GlucaGen] 1 mg 1 mg IM every
15 minutes Disp #*1 Kit Refills:*0
4. Calcium Carbonate 1000 mg PO BID
5. Calcium Carbonate ___ mg PO PRIOR TO HEMODIALYSIS ON ___,
___, AND ___
6. Calcium Carbonate 1500 mg PO DAILY WITH LARGEST MEAL
7. ClonazePAM 0.5 mg PO QHS:PRN insomnia
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 7.5 mg PO DAILY
RX *prednisone 2.5 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
RX *prednisone 5 mg 1 tablet(s) by mouth every morning Disp #*30
Tablet Refills:*0
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] 1 test
strip In morning, at lunch, dinner, and before bedtime Disp #*1
Box Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Per Sliding Scale Per
Sliding Scale subQ Up to 2 Units QID per sliding scale Disp #*1
Vial Refills:*0
RX *lancets 1 lancet in morning, lunch, dinner, and at bedtime
Disp #*1 Box Refills:*0
RX *insulin syringe-needle U-100 [Insulin Syringe] 30 gauge x
___ 1 Syringe as needed for Finger stick greater than or equal
to 250 Disp #*90 Syringe Refills:*0
12. Dialyvite (B complex-vitamin C-folic acid;<br>vit B cplx
___ ___ mg-mg-mcg-mg oral daily
13. Amoxicillin ___ mg PO PRIRO TO PROCEDURES
Take four (4) 500mg capsules once prior to procedures
14. HydrOXYzine 50 mg PO BID:PRN Itching
15. Lidocaine 5% Ointment 1 Appl TP PRN As directed
16. Alcohol Wipes (alcohol swabs) 1 wipe topical QID prior to
fingersticks
RX *alcohol swabs 1 wipe prior to checking fingerstick four
times daily Disp #*1 Box Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
-Hyperglycemia
-Hypertension
-Foot pain
SECONDARY
-End stage renal disease on hemodialysis
-Status post gastric bypass surgery
-Adrenal insufficiency
-Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with dyspnea and history of end-stage renal
disease with possible CHF.
COMPARISON: ___.
FINDINGS: PA and lateral views of the chest. Left chest wall port is seen
with catheter in stable position. The lungs remain clear without effusion,
consolidation, or pulmonary edema. The cardiomediastinal silhouette is
normal. No acute osseous abnormality is identified.
IMPRESSION: No acute cardiopulmonary process. No evidence of pulmonary
edema.
Radiology Report
INDICATION: Dyspnea and elevated D-dimer, on dialysis, evaluate for pulmonary
embolism.
COMPARISON: CT chest on ___.
TECHNIQUE: MDCT images were obtained through the chest with IV contrast.
Coronal and sagittal reformations were performed. Right and left MIP
reconstructions were performed.
Total DLP is 298 mGy-cm. Total CTDIvol is 17 mGy.
FINDINGS: The thyroid is normal. There is no axillary, mediastinal or hilar
lymphadenopathy. The aorta is normal in caliber. There are no filling
defects in the pulmonary arteries to the subsegmental level. There is a small
segment of focal narrowing in the right lower lobe subsegmental branch which
is chronic (2, 64). The visualized heart and pericardium are unremarkable.
There is no pericardial effusion. There is mild bibasilar atelectasis or
scarring which is unchanged. Otherwise lungs are clear and there is no
pleural effusion or pneumothorax. The airways are patent to the subsegmental
level.
No suspicious osseous abnormalities are seen. Left chest wall port is noted
with catheter tip in the mid SVC.
Limited evaluation of the intra-abdominal organs is unremarkable.
Post-surgical changes are seen in the upper abdomen including bypass surgery
and left sided incisional hernia is again noted.
IMPRESSION:
1. No evidence of pulmonary embolism. No other acute findings identified.
2. Mild bibasilar atelectasis/scarring.
Radiology Report
HISTORY: History of three failed renal transplants, now on hemodialysis with
evidence of right-sided transplanted kidney.
COMPARISON: Comparison is made with CT abdomen and pelvis from ___.
TECHNIQUE: Grayscale and color and spectral Doppler ultrasound images of the
renal transplant were obtained.
FINDINGS: The transplanted kidney in the right pelvis demonstrates echogenic
parenchyma. On color flow, and there is diminished overall flow in the renal
transplant. Acceleration times in the main renal artery were normal. There
is good venous drainage of the transplanted kidney. Resistive indices are
difficult to calculate due to artifact, but these appear to be probably
markedly elevated. There is no hydronephrosis and no perinephric fluid
collection. A small amount of free fluid is noted in the pelvis. The bladder
is empty. The native kidneys and left-sided old renal transplant were not
well visualized on this exam.
IMPRESSION: Globally decreased blood flow to the renal transplant, with
probably markedly elevated resistive indices.
Radiology Report
INDICATION: Pain along the lateral aspect of the mid foot.
COMPARISON: Left foot radiographs from ___.
FINDINGS: There is no acute fracture or dislocation. There is no periostitis
or evidence of cortical erosion. Mild degenerative changes are noted at the
first tarsometatarsal joint as well as the first metatarsophalangeal joint.
There is a tiny os peroneum. Vascular calcifications are noted. No soft
tissue abnormalities are identified.
IMPRESSION: No evidence of acute fracture or dislocation.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with ACIDOSIS, RESPIRATORY ABNORM NEC
temperature: 98.8
heartrate: 59.0
resprate: 16.0
o2sat: 100.0
sbp: 169.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with an extensive medical history notable
for hepatitis C, hypertension, and end-stage renal disease on
hemodialysis status post failed renal transplant x3 who
presented with dyspnea, found to have metabolic acidosis as well
as hyperglycemia. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dry mouth, poor appetite
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F pt with PMH of chronic pancreatitis who
presents with poor intake and dry mouth. She initially presented
to get a CT scan for Dr. ___ and told him that she had
been feeling unwell and she was referred to the ED. She says
that since ___, she has had dry mouth, and unable to drink a
lot of fluids. Her blood sugars were also rising from 160s to
400s over the last 2 days. She began having increasing thirst in
the last couple days and noticed she was urinating frequently.
She just returned 2 days ago from ___ where she was there for
a 5 day trip. For the past 4 days or so she has also had a dry
cough, but denies fevers, chills, sweats, productive cough or
SOB. Because her BG was high, she only took 10mg of prednisone
on ___ and took none today. She reports 5lb wt loss over the
last week and 10lbs over the last month. Last night she also had
loose, watery, ___ diarrhea that looked like "my food."
She denies any n/v/abdominal pain.
In the ED, initial vitals: 97.6 76 121/51 16 100%. On
examination, she appears frail, A&O x 3, EOMI, PERRL, Grade I/VI
systolic murmur RUSB, CTAB no wheezes, Abd ___,
___, Ext no edema. Neg Romberg. Normal strength upper
and lower extremities. ECG showed old LBBB. Labs were notable
for Na to 123, Glucose 418, AG 14, lactate 2.9, LFT's wnl, WBC
20.8, Hct 34.8. CXR was done which was unremarkable. CTAP done
showed pulmonary nodules but no acute ___ process.
UA showed 1000 glucose but no ketones, otherwise negative. She
was given 6 units of insulin x1 at 7pm.
Pt is a Mental Status: a&ox3, Lines & Drains: #18 RAC, Fluids: 2
LNS bolus. Vitals prior to transfer: 97.6 66 113/53 16 100%.
Currently, she feels improved and feels that her mouth is less
dry. No other current complaints.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Diabetes ___ type 2, diagnosed at age ___
- Autoimmune pancreatitis
- mildly abnormal kappa lambda ratio along with her hyperIgG
gammaglobulinemia
- Osteopenia
- HLD
- B12 defeiciency
- Hypothyroidism
- s/p TAH
- allergic rhinitis
- GERD
- LBBB
- left neck mass
- benign parotid gland resection
- psoriatic arthritis
- IgA deficiency
- C. diff colitis
- chronic pancreatitis: previous GI history in detail - ___,
with ___ watery, non bloody, BM's and wt loss. At first she was
diagnosed with C diff diarrhea but the symptoms continued after
treatment. suspected of celiac as well. Diagnosed with chronic
pancreatitis was supported by an abnormal fecal fat content and
an atrophized pancreas demonstrated on an MRCP, MRE and EUS. The
MRIs also demonstrated a dilated irregular pancreatic duct and a
mild narrowing of the distal CBD with no proximal dilatation.
There is no previous history of acute pancreatitis or alcohol
consumption.
The suspicion of celiac disease was due to the pathological
findings of areas with villous shortening in duodenal biopsies,
with infiltration of the mucosa with PMN and lympocytes.
Serology
testing was negative for tTG and anti DGP, but IgA was also low
(<4).
The patient was started treatment with ZENPEP and encouraged to
keep a gluten free diet.
Social History:
___
Family History:
Mother STROKE
Father MYOCARDIAL INFARCTION died at age ___
Brother DIABETES ___
Physical Exam:
Admission:
VS - Temp 98.0F, BP 108/48, HR 76, RR 18 , ___ 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, mildly dry MM,
OP clear
NECK - supple, no thyromegaly, no LAD, no JVD
HEART - RRR, nl ___, ___ systolic murmur LUSB
LUNGS - good air movement, faint crackles R base, no wheezes or
rales
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, + skin tenting
NEURO - awake, A&Ox3, CNs ___ grossly intact, moving all
extremities, gait deferred
Discharge:
Afebrile, normotensive
GENERAL - NAD, comfortable, appropriate
HEENT - MMM, OP clear
HEART - RRR, nl ___, ___ systolic murmur LUSB
LUNGS - good air movement, CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no edema
Pertinent Results:
Admission labs:
___ 05:00PM BLOOD ___
___ Plt ___
___ 05:00PM BLOOD ___
___
___ 05:00PM BLOOD ___
___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___ 05:43PM BLOOD ___
Discharge labs:
___ 06:30AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___
Imaging:
CXR ___:
FINDINGS:
PA and lateral views of the chest. The lungs remain clear of
consolidation.
Bilateral calcified granulomas and calcified left hilar lymph
nodes are again seen. The cardiomediastinal silhouette is within
normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
CTAP ___:
IMPRESSION:
1. Chronic pancreatitis, without acute inflammation or masses.
2. Cholelithiasis.
3. Bibasilar pulmonary opacities may represent aspiration or
early infection.
Micro:
Blood cultures ___ pending
___ 05:10PM BLOOD COCCIDIOIDES ANTIBODY,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. azelastine *NF* 137 mcg NU HS
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Flovent 110mcg 2 PUFF IH BID
with spacer
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Creon 12 3 CAP PO TID W/MEALS
7. Losartan Potassium 50 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. PredniSONE 30 mg PO DAILY
___ had discontinued this medication 1 day prior to admission
Tapered dose - DOWN
11. Simvastatin 20 mg PO DAILY
12. teriparatide *NF* 20 mcg/dose - 600 mcg/2.4 mL Subcutaneous
daily
13. Acetaminophen ___ mg PO Q6H:PRN pain
14. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 2,000 unit
Oral daily
15. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily
16. vitamins A,C,& ___ *NF* Oral daily
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Creon 12 3 CAP PO TID W/MEALS
4. Flovent 110mcg 2 PUFF IH BID
with spacer
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. azelastine *NF* 137 mcg NU HS
11. Glucosamine *NF* (glucosamine sulfate) 500 mg Oral daily
12. teriparatide *NF* 20 mcg/dose - 600 mcg/2.4 mL Subcutaneous
daily
13. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 2,000 unit
Oral daily
14. vitamins A,C,& ___ *NF* 0 ORAL DAILY
15. PredniSONE 30 mg PO DAILY
___ had discontinued this medication 1 day prior to admission
Tapered dose - DOWN
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*13
Tablet Refills:*0
16. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [One Touch Ultra Test] Check blood
glucose QACHS (4 times daily) Disp #*50 Unit Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL SQ injection 5 Units
before BED Disp #*100 Unit Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL Up to 7 Units per
sliding scale QACHS Disp #*3 Vial Refills:*1
RX *lancets [One Touch SureSoft Lancing Dev] For use
monitoring blood sugar QACHS Disp #*50 Unit Refills:*0
RX *insulin ___ [Insulin Syringe] 30 gauge x
___ For insulin administration QACHS Disp #*60 Syringe
Refills:*0
17. Dex4 Glucose *NF* (dextrose;<br>glucose) 4 gram Oral PRN
FSBG < 70
Take 4 tablets for blood glucose < 70 and recheck fingerstick in
15 minutes.
RX *glucose [Dex4 Glucose] 4 gram 4 tablet(s) by mouth As
directed Disp #*100 Tablet Refills:*0
18. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hyperglycemia
Hyponatremia
Dehydration
Cough
Secondary:
Diabetes ___
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chronic pancreatitis with five days of anorexia, nausea, and
weight loss.
COMPARISON: CT abdomen/pelvis from ___, MRCP from ___, MR
enterography from ___.
TECHNIQUE: Helical MDCT images were acquired from the lung bases through the
iliac crests before and after uneventful administration of 150 cc of
intravenous Omnipaque, with imaging in the noncontrast, late arterial, and
venous phases. 5- and 2.5-mm axial, 5-mm coronal and sagittal multiplanar
reformats were generated. Maximum intensity projection images of the
pancreatic arterial and venous vasculature, as well as minimum intensity
projections of the pancreatic duct, were generated at a separate workstation
by the advanced imaging lab, and were esential for diagnosis.
FINDINGS: Interval calcification of multiple sub-4-mm pulmonary nodules at
the right lung base. New patchy bibasilar ground-glass opacities in a
peribronchiolar distribution. No pleural effusions. Heart is normal in size,
without pericardial effusion. Relative hypoattenuation of the blood pool is
compatible with anemia.
ABDOMEN: Calcified granulomas in the liver. No liver masses or abnormal foci
of enhancement. Note is made of focal fat deposition along the falciform
ligament. No intrahepatic biliary ductal dilation. Numerous calcified
gallstones, one of which is partially impacted at the neck. No gallbladder
distension, wall edema, fat stranding, or pericholecystic fluid.
The pancreas remains diffusely atrophic, with slightly decreased overall
enhancement. No discrete calcifications. No fat stranding or peripancreatic
fluid. Pancreatic duct is enlarged to 3-4 mm and diffusely irregular. No
space-occupying lesions.
Calcifications and numerous hypodensities throughout the spleen, possibly
noncalcified granulomas.
The adrenals are normal. Kidneys enhance and excrete contrast promptly and
symmetrically, without stones, masses, or hydronephrosis. Multiple bilateral
simple cysts, better characterized on MR.
___: The colon and rectum are within normal limits. Bladder is partially
decompressed, with bilateral ureteral jets. Uterus is surgically absent, with
intact vaginal cuff. Trace free fluid in the pelvis. No lymphadenopathy or
free air.
Severe loss of disc space at L4-L5 and L5-S1, with endplate sclerosis,
intervertebral vacuum disc phenomenon, and anterior-posterior disc osteophyte
complexes. Ligamentum flavum thickening and facet joint hypertrophy in the
lumbar spine. Mild sacroiliac and hip joint degenerative changes.
CT ANGIOGRAPHY: Mild calcification throughout the abdominal aorta and iliac
arteries, without flow-limiting stenosis.
The portal, hepatic, splenic, superior mesenteric veins and IVC are widely
patent.
IMPRESSION:
1. Chronic pancreatitis, without acute inflammation or masses.
2. Cholelithiasis.
3. Bibasilar pulmonary opacities may represent aspiration or early infection.
Radiology Report
HISTORY: ___ female with history of chronic pancreatitis, diabetes,
hypothyroidism with anorexia. Poor PO intake, question pneumonia.
COMPARISON: Chest x-rays from ___ and ___.
FINDINGS:
PA and lateral views of the chest. The lungs remain clear of consolidation.
Bilateral calcified granulomas and calcified left hilar lymph nodes are again
seen. The cardiomediastinal silhouette is within normal limits. Osseous and
soft tissue structures are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HYPERGLYCEMIA
Diagnosed with DIABETES UNCOMPL ADULT, ANOREXIA
temperature: 97.6
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | Brief Course:
Ms. ___ is a ___ F pt with PMH of chronic pancreatitis who
presents with poor intake and dry mouth, found to have
hyperglycemia and dehydration, likely secondary to recent
corticosteroid use.
#. Hyperglycemia: Pt with DM type 2, poorly controlled currently
likely due to recent prednisone use, most recent A1c 7.0. At
home, pt is only on Metformin BID. Pt has UA with 1000 glucose
but no ketones, pH from VBG is 7.31, and no AG acidosis. Pt was
hydrated and given insulin in house and her glucose control. She
was restarted on the corticosteroids per GI recs, and was
discharge on Lantus insulin with a sliding scale while on
prednisone. She was given instructions to call if BG
persistently high.
#. Leukocytosis: Most likely ___ recent steroids vs. infection.
Pt with ___ cough, nd pulmonary nodules seen on CT
(see below), though CXR clear. No other localizing symptoms.
Blood cultures were sent and pending on discharge. Her WBC was
trended and decreased but remained elevated likely secondary to
corticosteroids. See below re: ground glass nodules.
#. Ground glass nodules in lungs: Seen in lung views of CTAP.
New since ___, as above, thought most likely infectious in
etiology. CXR was clear. Recent travel to ___ and could
considered coccidomycosis; less likely given region are other
fungal etiologies such as histoplasmosis and blastomycosis.
Other ddx includes bacterial infection, though syx not
consistent with PNA given ___ cough and afebrile.
Other etiologies considered include pneumoconioses or
malignancy. Sent coccidioides serology, which was pending on
discharge. Given afebrile and pt feeling well, pt was not
started on empiric treatment.
# Chronic autoimmune pancreatitis: Pt sees Dr. ___, Dr.
___ Dr. ___ her chronic diarrhea and autoimmune
pancreatitis. ESR done grossly elevated in ___. Pt has been
on prednisone for 2.5 weeks for planned 3 week course then taper
prior to admission. However, she had ___ 1 day
prior for hyperglycemia as above. Contacted her outpatient
providers via email on patient's admission. Her prednisone was
continued with treatment for hyperglycemia as above. She was
seen briefly by GI who recommended start to taper steroids and
for her to ___ with Dr. ___ as previously scheduled
for EUS on ___.
# Weight loss: possibly ___ poor po intake from infection as
discussed above vs. malignancy vs. chronic pancreatitis. CTAP
ordered by Dr. ___ during this admission showing no
mass, though continued pancreatic duct abnormality. Nutrition
saw her and she recommended supplementation in house. She will
required close ___ with her outpatient providers.
#. Hyponatremia: Likely pseudohyponatremia ___ hyperglycemia and
hypovolemia. She corrected with IVF's and treatment of
hyperglycemia.
#. Hypothyroidism: Continued Levothyroxine 112mcg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Ceclor / house dust / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PRIMARY ONCOLOGIST: ___, MD
___, MD
PRIMARY CARE PHYSICIAN: ___, MD
PRIMARY DIAGNOSIS: Locally advanced pancreatic adenocarcinoma
TREATMENT REGIMEN: FOLFOX (___)
CC: fever, rash
HISTORY OF PRESENTING ILLNESS:
Mrs. ___ is a ___ year-old lady with borderline resectable
pancreatic adenocarcinioma on FOLFOX, c/b E.coli sepsis, liver
abscess, PE and cervical fracture, who is admitted from the ED
with rash and fever.
Over the last two days, patient developed new erythematous
raised rash on the right side of her abdomen and umbilicus. She
developed chills on ___, and on day of admission she developed
fever to 100.6. She defervesced without intervention. She called
her oncologist and was directed into the ED.
ED initial vitals were 98.5 80 128/67 18 97%RA. Prior to
transfer vitals were 99.2 82 122/68 18 95%RA
Exam in the ED showed : "Comfortable Two areas of induration
with overlying erythema near injection sites"
ED work-up significant for:
-CBC: 8.6 > 8.0 < 68
-Chemistry: 137/3.5 | ___ | ___
-Lactate:1.3
-Coags: INR 1.2, PTT 32.8
-LFTs: ___ | 176/0.3
-UA: 1WBC, nit-
-CXR:No acute cardiopulmonary process.
-CT AP: "No acute findings in the abdomen or pelvis. Unchanged
0.5 cm hypodensity in hepatic segment III is consistent with
residual microabscess. No other liver lesions identified.
Pancreatic head mass with upstream pancreatic ductal dilatation,
not dramatically changed noting accurate assessment is limited
given single phase exam. Re-demonstration of multiple nodular
hyperdense lesions in the subcutaneous anterior abdominal fat.
These likely represent injection granulomas. Please correlate
with clinical history."
ED management significant for:
-Medications: 1L NS, vancomycin 1g iv x1, home meds
On arrival to the floor, patient reports ongoing pain in her
lower abdominal wall and neck. She reports feeling very anxious
about needing more enoxaparin shots as they have become very
painful in the past two days.
Patient denies night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
___ is a ___ woman previously treated
for, chronic pancreatitis and surveilled with endoscopic
ultrasound and CT scans as well as a history of fibromyalgia,
chronic back pain on opiates, and an type 2 diabetes mellitus
who presented to the emergency department at ___
___ ___ with 10 days of epigastric pain radiating to
her mid back and fever. This was associated with pale stools
jaundice and an unintentional 40 pound weight loss over the past
year. Her bilirubin was 14, and CT raise concern for biliary
dilatation. She was transferred to ___ where she underwent CT
angiogram. The study identified a mass in the head of the
pancreas with associated pancreatic ductal dilatation. As well
as enlarged peripancreatic and retroperitoneal lymphadenopathy.
She underwent endoscopic ultrasound and ERCP with biliary stent
placement. Brushings and fine-needle biopsy from the common
bile duct were positive for adenocarcinoma. Her course was
complicated by cholangitis and E. coli bacteremia for which she
is completing a 14 day course of IV antibiotics at the ___
___ nursing facility. CT scan nodularity concerning
for metastatic disease and a laparoscopic evaluation is
recommended for further assessment. She underwent laparoscopy
with biopsy negative for metastatic disease.
Decision was made to pursue initial chemotherapy with FOLFOX
consideration uptitration to FOLFIRINOX. We will also consider
radiation therapy with CyberKnife SBRT.
- ___ C1D1 FOLFOX
- ___ - ___: Admitted with facial swelling and redness.
C/f cellulitis vs angioedema. Treated with antibiotics,
steroidsand antihistamines. DC'd lisinopril.
- ___: ED visit with persistent facial redness.
Prescribedlonger course of steroids for concern of poison ___
- ___ - ___: Admitted for cholangitis/sepsis. ERCP on
___. Blood cultures on ___ grew Klebsiella, E. Coli,
Aeromonas hyrophila, and Enterococcus avium. CT abd/pelv showing
new liver abscesses, which were not amenable to drainage. Also
found to have new PE. Completed course of meropenem/ertapenem.
- ___ - ___: Admitted following fall at home with C2
fracture. Non-operative management with hard collar. Course
complicated by persistent pain. Stopped Lasix.
- ___: C2D1 FOLFOX while inpatient (second overall dose)
- ___: Presented to clinic for C2D15 FOFLOX. Dose
held and patient admitted to hospital for hypoxia. CTA without
progression of known PE. Continued to have issues with pain.
Started gabapentin. Switched tizanidine to qhs only.
- ___: C3D1 FOLFOX (third overall dose)
Past Medical History:
1. Asthma with seasonal allergies
2. Tobacco use
3. History of lymphedema
4. History of non-insulin-dependent type 2 diabetes mellitus
5. History of chronic pancreatitis
6. GERD
7. History of UTI
8. History of pneumonia
9. History of urinary incontinence status post urethral surgery
___. Depression/anxiety/panic disorder
11. Fibromyalgia
13. Status post back and neck surgery
___. h/o periorbital cellulitis
15. Status post C-section ×3
16. Status post hysterectomy for endometriosis
17. Status post cholecystectomy
___. Status post umbilical hernia repair
19. Pulmonary Embolism
20. C2 fracture s/p fall
___. h/o liver abscess and E coli bacteremia
Social History:
___
Family History:
The patient's father died at ___ years with pancreatitis. Her
mother died at ___ years with diabetes mellitus and congestive
heart failure. She had 11 siblings. 2 brothers and 2 sisters
have been treated for pancreatic cancer at ages ___, ___, ___, and
___. A nephew was also treated for pancreatic cancer at ___
years. A niece died following resection of a benign pancreatic
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 101.3 120 / 64 103 18 95 RA
GENERAL: Well-appearing lady, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Multiple 2-3cm tender, nodular and erythematous lesions in
R>L lower quadrants of the abdominal wall, in RLQ they coalesce
in ~10x8cm erythematous lesion, abdomen, non-distended, normal
bowel sounds, soft, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to light touch intact.
SKIN: As above. Right chest port without secretion. Mild
tenderness and erythema in lower surrounding area.
DISCHARGE PHYSICAL EXAM:
VS: 98.0 128 / 60 64 18 93% RA
GENERAL: awake, neck brace on, very emotional this morning
HEENT: MM dry
NECK: neck brace in place
CV: RRR, no murmurs
PULM: CTA anteriorly
ABD: soft, non-distended, erythematous nodules along the RLQ and
left pelvis, erythema is receding from drawn line, still diffuse
tenderness but improved.
EXT: wwp, no edema
Pertinent Results:
ADMISSION LABS:
___ 07:08PM BLOOD WBC-8.6 RBC-3.01* Hgb-8.0* Hct-25.9*
MCV-86 MCH-26.6 MCHC-30.9* RDW-15.4 RDWSD-47.8* Plt Ct-68*#
___ 07:08PM BLOOD Neuts-51 Bands-1 ___ Monos-6 Eos-4
Baso-0 ___ Myelos-0 AbsNeut-4.47 AbsLymp-3.27
AbsMono-0.52 AbsEos-0.34 AbsBaso-0.00*
___ 07:08PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:08PM BLOOD ___ PTT-32.8 ___
___ 07:08PM BLOOD Glucose-145* UreaN-8 Creat-0.6 Na-137
K-3.5 Cl-99 HCO3-27 AnGap-11
___ 07:08PM BLOOD ALT-7 AST-11 AlkPhos-176* TotBili-0.3
___ 07:08PM BLOOD Albumin-3.3*
___ 05:19AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.7
___ 07:13PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 05:02AM BLOOD WBC-5.8 RBC-2.96* Hgb-7.7* Hct-25.9*
MCV-88 MCH-26.0 MCHC-29.7* RDW-16.1* RDWSD-49.3* Plt Ct-91*
___ 05:02AM BLOOD Neuts-37 Bands-0 ___ Monos-15*
Eos-9* Baso-0 Atyps-3* Metas-1* Myelos-5* NRBC-3* AbsNeut-2.15
AbsLymp-1.91 AbsMono-0.87* AbsEos-0.52 AbsBaso-0.00*
___ 05:02AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-1+* Microcy-NORMAL Polychr-1+* Ovalocy-1+*
___ 05:37AM BLOOD ___ PTT-27.8 ___
___ 05:02AM BLOOD Glucose-146* UreaN-8 Creat-0.6 Na-140
K-4.0 Cl-101 HCO3-29 AnGap-10
___ 05:02AM BLOOD ALT-7 AST-11 LD(LDH)-236 AlkPhos-137*
TotBili-<0.2 DirBili-<0.2
___ 05:02AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.3 Mg-2.0
MICROBIOLOGY:
BLOOD CULTURES - NEGATIVE, NO GROWTH TO DATE
MRSA SCREEN - NEGATIVE
URINE CULTURE - NORMAL FLORA
IMAGING:
___ CTA ABDOMEN/PELVIS IMPRESSION:
1. No acute findings in the abdomen or pelvis.
2. Unchanged 0.5 cm hypodensity in hepatic segment III is
consistent with residual microabscess. No other liver lesions
identified.
3. Pancreatic head mass with upstream pancreatic ductal
dilatation, not dramatically changed noting accurate assessment
is limited given single phase exam.
4. Re-demonstration of multiple nodular hyperdense lesions in
the subcutaneous anterior abdominal fat. These likely represent
injection granulomas. Please correlate with clinical history.
___ CXR IMPRESION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO TID:PRN anxiety
2. Creon ___ CAP PO QIDWMHS
3. Docusate Sodium 100 mg PO BID constipation
4. DULoxetine 60 mg PO BID
5. Enoxaparin Sodium 80 mg SC Q12H
6. Fentanyl Patch 100 mcg/h TD Q72H
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Simethicone 40-80 mg PO QID:PRN bloating
12. dexlansoprazole 30 mg oral BID
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
14. Lactulose 15 mL PO PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 capsule(s) by mouth every 8 hours
Disp #*90 Capsule Refills:*0
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*0
3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
RX *calcium carbonate-vitamin D3 [Calcium 500 + D (D3)] 500 mg
calcium (1,250 mg)-125 unit 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 g IV once a day Disp #*10 Vial
Refills:*0
5. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily with
meals Disp #*30 Capsule Refills:*0
7. ALPRAZolam 1 mg PO TID:PRN anxiety
8. Creon ___ CAP PO QIDWMHS
9. dexlansoprazole 30 mg oral BID
10. Docusate Sodium 100 mg PO BID constipation
11. DULoxetine 60 mg PO BID
12. Fentanyl Patch 100 mcg/h TD Q72H
13. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
15. Lactulose 15 mL PO PRN constipation
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Senna 8.6 mg PO BID:PRN constipation
19. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
========================
Abdominal wall cellulitis
SECONDARY DIAGNOSES:
========================
Locally advanced pancreatic cancer
C2 neck fracture, pain
History of DVT, PEs
GERD
Pancreatic exocrine insufficiency
Diabetes mellitus type II
Heart failure with reduced ejection fraction
Paroxysmal atrial fibrillation
Anxiety
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 fever, possible neutropenia// PNA
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Right chest wall port is stable in position. The lungs are clear without
consolidation, effusion, or edema. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT ABDOMEN PELVIS WITH CONTRAST
INDICATION: ___ with pancreatic CA on chemo, hx liver abscess, p/w
feversNO_PO contrast// Evolution/new hepatic abscess, soft tissue abscess vs
hematomas in lower abdomen, other pathology?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,101 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
0.5 cm hypodensity in segment III (2:23) is unchanged from prior. No other
focal lesions are seen. A metallic CBD stent is again noted. Pneumobilia is
present, compatible with stent patency. The gallbladder is surgically absent.
PANCREAS: The pancreas is diffusely atrophic. Ill-defined mass at the
pancreatic head is again seen though exact measurements are difficult on this
single-phase exam. There is apparent enlargement with more soft tissue
anterior to the stent. Mass measures approximately 4.5 x 3.5 cm, previously
estimated at 4.2 x 3.3 cm. There is dilation of the pancreatic duct
throughout its course. Dilated pancreatic duct throughout the remaining
portion of the pancreas with likely dilated side branches near the tail is
similar in appearance compared to recent prior exams.
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.
A subcentimeter hypoattenuating lesion is again seen in the right interpolar
region, too small to characterize, but unchanged from prior. There is no
hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is no evidence of
gastrointestinal obstruction. There is no free intra-abdominal fluid or air.
The appendix is normal.
PELVIS: The bladder is mostly decompressed. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is not seen. No adnexal masses.
LYMPH NODES: Prominent retroperitoneal lymph nodes measuring up to 8 mm in the
left para-aortic station (2:31) are similar to prior. There is no pelvic or
inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Re-demonstration of multilevel degenerative changes and levoscoliosis of the
lumbar spine.
SOFT TISSUES: Multiple nodular hyperattenuating lesions are again seen in the
subcutaneous fat of the anterior abdominal wall, similar to prior likely from
subcutaneous injections. There is a small fat containing umbilical hernia.
IMPRESSION:
1. No acute findings in the abdomen or pelvis.
2. Unchanged 0.5 cm hypodensity in hepatic segment III is consistent with
residual microabscess. No other liver lesions identified.
3. Pancreatic head mass with upstream pancreatic ductal dilatation, not
dramatically changed noting accurate assessment is limited given single phase
exam.
4. Re-demonstration of multiple nodular hyperdense lesions in the subcutaneous
anterior abdominal fat. These likely represent injection granulomas. Please
correlate with clinical history.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Cellulitis of abdominal wall, Unspecified atrial fibrillation
temperature: 98.5
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 128.0
dbp: 67.0
level of pain: 7
level of acuity: 3.0 | SUMMARY:
==================
Mrs. ___ is a ___ year old female with borderline
resectable pancreatic adenocarcinioma on FOLFOX, c/b recurrent
E.coli bloodstream infections, liver abscess, PE and cervical
fracture, who is admitted from the ED with painful abdominal
rash and fever.
#ABDOMINAL WALL CELLULITIS:
The patient has known foreign body granulomas on her abdomen
secondary to twice daily lovenox injections. These nodular
lesions on had been present for weeks but two days prior to
admission they coalesced and became tender with erythema and
fever. Peak temperature 101.4, afebrile since admission. She has
a history of several drug allergies and infections with
multi-resistant GNRs, making antibiotic choice difficult. She
was initially started on vancomycin and meropenem, but given the
high fevers and no prior culture data suggestive of MRSA
colonization, vancomycin was peeled off for presumed strep
cellulitis of the abdominal wall. MRSA nasal swab came back
negative. She was discharged on ertapenem for a 14 day course
(___).
#CANCER PAIN:
Well controlled apart from neck pain. Abdomen still tender to
palpation, no peritoneal signs.
- Fentanyl patch 100mcg q72 hours
- Hydromorphome ___ po q3 hours prn
- Duloxetine 60 mg bid
- Aggressive bowel regimen, standing colace, senna, miralax and
PRN lactulose
#HISTORY OF VTE
Given infection ___ lovenox injection and frequent discomfort
with injections, she was transitioned to apixaban 5mg PO BID by
discharge.
#C2 FRACTURE:
- Persistent, right sided pain
- Hard collar at all times, advised to use a recliner
- Started on calcium, vitamin D separately while inpatient,
transitioned to combined medication outpatient
- Plan to see Neurosurgery on ___
#GERD: Continue home dexlansoprazole 30mg daily
#LOCALLY ADVANCED PANCREATIC CANCER:
#S/P C3D1 FOLFOX ___.
She has had multiple interruptions and delays in her neoadjuvant
course due to recurrent hospitalizations and serious infections.
CT in ED showed interval enlargement in pancreatic mass.
- Counts have stabilized
- Active TS
- Transfuse for Hb < 7
- Will touch base with Dr. ___ discharge for continued
care
#PANCREATIC EXOCRINE INSUFFICIENCY W/ H/O CHRONIC PANCREATITIS:
- Creon ___ caps QIDWMS
#DIABETES: Lispro SS, did not require while inpatient
#dCHF:
#pAF:
- no longer on furosemide
- has not required nodal agent
- Starting anticoagulation with apixiban 5mg PO BID (___)
#ANXIETY: Continue home alprazolam and duloxetine |
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, ___ edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with history of morbid obesity,
hypertrophic cardiomyopathy (EF >55% ___, OSA on 2L O2, and
afib on rivaroxaban who presents with bilateral lower extremity
edema and dyspnea. She was recently admitted ___ with
HFpEF
exacerbation at which time she was diuresed with a Lasix gtt at
30 cc/hr. On discharge her weight was 300.9 lbs. She says that
she was initially doing OK after discharge but in the last week
has had increased ___ edema and dyspnea. She has been taking her
medication, including torsemide, and states has been compliant
with low salt diet.
She also has had nausea, vomiting, and diarrhea in the last ___
days. No fevers. Her cough is at baseline. No chest pain. She
has
lower back pain that bothers her as well as numbness in her
lateral/anterior right thigh.
In the ED, initial VS were: 98.3 F, HR 104, BP 130/80s, RR 16,
99% RA
Exam notable for:
3+ pitting edema
tearful and anxious
Labs showed:
WBC 14, Hgb 11.5, plts 334
BNP 2727, trop <0.01 and CKMB 2
INR 1.2
LFTs within normal limits, bili 0.4
K 3.1, bicarb 35, Cr 1.0
UA with small leuks and few bacteria
Imaging showed:
CHEST X-RAY:
No focal consolidation or pulmonary edema. Stable cardiomegaly.
HIP X-RAY:
No fracture or dislocation.
Patient received:
100 mg IV lasix x1
PO and IV potassium
Tylenol
Lidocaine patch
Transfer VS were: 99 130/88 18 98% RA
On arrival to the floor, patient reports ongoing discomfort in
her back and numbness in her leg. Mildly SOB but generally worse
with exertion. Otherwise as above.
Past Medical History:
Hypertrophic cardiomyopathy (LVH (2.6/1.5), LVEF >75%, LVOTO
25-->98 mmHg, nl valves.)
Paroxysmal Afib
Hypertension
Morbid Obesity
GERD
OSA not on CPAP
Cholelithiasis
Depression
Impaired glucose tolerance
Colon polyps
CKD
Asthma
Social History:
___
Family History:
Father: Died of MI at ___
Brother: MI at ___- s/p 3 vessel CABG at ___; SLE.
Mother: colon cancer, died while on dialysis, asymmetric septal
hypertrophy
Son: CAD; s/p stent placement age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.5 ___ 20 98 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, conjunctivae noninjected, MMM
NECK: unable to assess JVP
HEART: RRR, S1/S2, soft systolic murmur without radiation
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mild ttp in LLQ without rebound, guarding, or rigidity
EXTREMITIES: ___ pitting edema in bilateral ___ with venous
stasis changes bilaterally
PULSES: 2+ DP pulses bilaterally
BACK: no midline tenderness, mild lumbar/sacral paraspinous
tenderness on R
NEURO: A&Ox3, moving all 4 extremities with purpose
DICHARGE PHYSICAL EXAM
GENERAL: Obese female sitting at bedside. NAD.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI. MMM.
LUNGS: CTAB, no wheezes, rales, or rhonchi.
HEART: RRR, no murmurs, rubs, or gallops
ABDOMEN: Soft, nontender, nondistended. NABS
EXTREMITIES: 1+ pitting edema of the feet, trace edema of the
legs above the ankles
NEURO: CNII-XII grossly intact. No focal deficits.
MSK: Tenderness to palpation of lateral aspect of left knee. ROM
limited due to pain. ___ strength. Allodynia of plantar and
dorsal aspect of L foot.
SKIN: No rashes or lesions noted. Chronic stasis changes
bilaterally.
Pertinent Results:
ADMISSION LABS
___ 01:26AM BLOOD WBC-14.0* RBC-4.47 Hgb-11.5 Hct-37.9
MCV-85 MCH-25.7* MCHC-30.3* RDW-20.0* RDWSD-61.5* Plt ___
___ 01:26AM BLOOD Neuts-73.3* ___ Monos-6.5
Eos-0.5* Baso-0.1 Im ___ AbsNeut-10.23* AbsLymp-2.68
AbsMono-0.91* AbsEos-0.07 AbsBaso-0.02
___ 01:26AM BLOOD ___ PTT-26.1 ___
___ 01:26AM BLOOD Glucose-118* UreaN-28* Creat-1.0 Na-146
K-3.1* Cl-97 HCO3-35* AnGap-14
___ 01:26AM BLOOD CK-MB-2 proBNP-2727*
___ 01:26AM BLOOD cTropnT-0.01
___ 01:26AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.7 Mg-1.7
DISCHARGE LABS
___ 08:45AM BLOOD WBC-11.0* RBC-4.72 Hgb-12.2 Hct-39.8
MCV-84 MCH-25.8* MCHC-30.7* RDW-18.7* RDWSD-57.9* Plt ___
___ 08:45AM BLOOD Plt ___
___ 08:45AM BLOOD Glucose-270* UreaN-52* Creat-1.4* Na-139
K-3.7 Cl-90* HCO3-31 AnGap-18
___ 08:45AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
MICRO
---------
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES
------------
Right hip x-ray ___
No fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO TID:PRN
reflux
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Benzonatate 100 mg PO TID cough
6. Capsaicin 0.025% 1 Appl TP Q8H:PRN leg pain
7. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
8. Dextromethorphan Polistirex ___ mg PO Q12H:PRN refractory
cough
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
10. Levalbuterol Neb 0.63 mg NEB Q6H:PRN wheezing
11. Lidocaine 5% Ointment 1 Appl TP BID:PRN ___ pain
12. Metoprolol Succinate XL 75 mg PO DAILY
13. Pantoprazole 40 mg PO Q12H
14. QUEtiapine Fumarate 12.5 mg PO QHS
15. Ranitidine 150 mg PO QHS
16. Rivaroxaban 20 mg PO DAILY
17. Torsemide 100 mg PO BID
18. Cetirizine 10 mg PO DAILY
19. Fluticasone Propionate 110mcg 2 PUFF IH BID
20. albuterol sulfate 2 puffs inhalation Q4H:PRN SOB
21. Miconazole Powder 2% 1 Appl TP TID:PRN Erythema on skin
folds on lower abdomen/GU region
22. Spironolactone 25 mg PO DAILY
23. Potassium Chloride 20 mEq PO DAILY
24. Gabapentin 600 mg PO TID
25. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
26. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Discharge Medications:
1. Gabapentin 600 mg PO BID
RX *gabapentin 600 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Torsemide 100 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. albuterol sulfate 2 puffs inhalation Q4H:PRN SOB
7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO TID:PRN
reflux
8. Amiodarone 200 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Benzonatate 100 mg PO TID cough
11. Capsaicin 0.025% 1 Appl TP Q8H:PRN leg pain
12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
13. Cetirizine 10 mg PO DAILY
14. Dextromethorphan Polistirex ___ mg PO Q12H:PRN refractory
cough
15. Fluticasone Propionate 110mcg 2 PUFF IH BID
16. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
18. Levalbuterol Neb 0.63 mg NEB Q6H:PRN wheezing
19. Lidocaine 5% Ointment 1 Appl TP BID:PRN ___ pain
20. Miconazole Powder 2% 1 Appl TP TID:PRN Erythema on skin
folds on lower abdomen/GU region
21. Pantoprazole 40 mg PO Q12H
22. Potassium Chloride 20 mEq PO DAILY
23. QUEtiapine Fumarate 12.5 mg PO QHS
24. Ranitidine 150 mg PO QHS
25. Rivaroxaban 20 mg PO DAILY
26. Spironolactone 25 mg PO DAILY
27.Outpatient Lab Work
ICD 10: N17.9 Acute Kidney Injury
When: ___
What: ___
Fax result to: ___ (PCP ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Acute on chronic HFpEF
Secondary Diagnoses
Hypertrophic cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with SOB// edema
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple prior chest radiographs most recently ___.
FINDINGS:
Lungs are moderately well expanded without focal consolidation or pulmonary
edema. Cardiomegaly appears stable. No pneumothorax or pleural effusion.
IMPRESSION:
No focal consolidation or pulmonary edema. Stable cardiomegaly.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ year old woman with R radiating hip pain// r/o fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: CT of the abdomen pelvis from ___.
FINDINGS:
There is no fracture or dislocation. There are no gross degenerative changes.
There is no suspicious lytic or sclerotic lesion. Bowel gas obscures the
sacrum. No radio-opaque foreign body.
IMPRESSION:
No fracture or dislocation.
RECOMMENDATION(S): If concern for occult fracture, consider CT or MRI.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF w/cough// Signs of PNA
IMPRESSION:
In comparison with the study of ___, there is stable enlargement of the
cardiac silhouette without vascular congestion, pleural effusion, or acute
focal pneumonia. The discordance raises the possibility of cardiomyopathy or
even pericardial effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with HF// Interval change
TECHNIQUE: PA and lateral views of the chest
COMPARISON: ___ chest x-ray and chest CT ___
FINDINGS:
The lungs are clear.
Moderate cardiomegaly stable.
No significant pleural effusion or pneumothorax.
IMPRESSION:
No acute pulmonary disease.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea, Leg swelling
Diagnosed with Heart failure, unspecified
temperature: 98.3
heartrate: 104.0
resprate: 16.0
o2sat: 99.0
sbp: 135.0
dbp: 82.0
level of pain: 9
level of acuity: 2.0 | ___ year old female with morbid obesity, hypertrophic
cardiomyopathy (EF >55% ___, OSA on 2L O2, and afib on
rivaroxaban who presents with bilateral lower extremity edema
and dyspnea c/w HFpEF exacerbation.
#Acute on chronic HFpEF
Patient presented with volume overload and a BNP 2727
approximately 2 weeks after being discharged for heart failure
exacerbation. Etiology of her decompensation was uncertain, as
patient reported adherence to her dietary restrictions and
medication regimen. Her troponins were negative. She was on
continuous telemetry monitoring without any signs of arrhythmia.
While she presented with complaints of 1 day of nausea,
vomiting, and diarrhea, these symptoms seemed to post-date her
heart failure exacerbation and therefore were unlikely inciting
factors. The patient was started on a lasix gtt with a max rate
of 30mg/hr in order to achieve adequate diuresis. She developed
an ___, likely from diuresis, which remained stable at
discharge. She was transitioned to PO diuretics, which were
titrated to maintain euvolemia and electrolyte balance. At time
of discharge, her diuretic regimen was torsemide 100mg daily,
but may need to be uptitrated as an outpatient.
Discharge weight: 135.7 kg
Discharge Cr: 1.4
Baseline Cr: 1.1
# Left anterolateral thigh parasthesia: She endorsed significant
pain of the right thigh area, suspicious for meralgia
paraesthetica given distribution vs. iliotibial syndrome. Pain
service was consulted, who felt it was more likely IT syndrome
and recommended ___ consult, and commented that there is no role
for injection. Her gabapentin was changed to 600 mg BID due to
renal insufficiency. Pain was managed with Tylenol, tramadol,
capsaicin, heat/ice, and lidocaine patches. Can consider a psych
evaluation as an outpatient for anxiety/stress that may be
worsening pain.
# L Knee pain
Patient with hx of osteoarthritis. Increased pain after
increased weight-bearing activity with ambulation and shower.
Chronic pain service was consulted, who recommended a lidocaine
patch 5% TD 12 hours ON/OFF.
Chronic Issues
# pAF: On prior admission risks and benefits of NOACs vs.
Warfarin were discussed and she preferred NOAC. Has declined
ablation. We continued her home Rivaroxaban, and increased her
home metoprolol to xl 100 mg daily. We also continued home
amiodarone.
# Chronic cough: at baseline per patient, continued home
benzonatate, guaifenesin; continued home inhalers
# Depression: Continued quetiapine
# OSA: Continued 2L O2 at night
# GERD: Continued home pantoprazole and ranitidine. Continued
aluminum/magnesium simethicone
# HLD: Continued home atorvastatin
# NIDDM: A1c 7.4 on ___. ISS
# Peripheral neuropathy: Continued gabapentin (at a lower dose
due to ___ and acetaminophen
Transitional Issues
#Diuretic regimen: the patient was discharged on torsemide 100mg
PO daily. This regimen was sufficient to maintain euvolemia and
electrolyte balance in the hospital, however should be revisited
in the outpatient setting when the patient resumes her usual
diet.
#Anticoagulation: The patient presented on rivaroxaban for
anticoagulation in setting of paroxysmal atrial fibrillation.
Given her obesity, NOACs such as rivaroxaban may not be as
effective as warfarin. Previous discharge summaries have stated
that this was addressed with the patient and that the patient
had refused a change to warfarin. This should be revised with
the patient.
[ ] Please recheck chem-7 as an outpatient on ___ to
follow-up on ___. Baseline creatinine 1.0-1.1, but discharge
creatinine 1.4, which may be ___ from diuresis.
Discharge weight: 135.7 kg
Discharge Cr: 1.4 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sudafed / Toradol / Levaquin / iv contrast /
Amitriptyline / Motrin / Ultram / acetaminophen / latex tape /
gabapentin / Protonix
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ transgender woman with
history
of paraplegia ___ MVC, neurogenic bladder s/p ileal conduit +
urostomy, PE in setting of PICC (not on anticoagulation), COPD
(on 2L home O2), pyelonephritis, recurrent SBO, chronic
constipation presenting with hematemesis and concern for bowel
obstruction.
Patient with chronic constipation but reports no bowel movement
or flatus for 4 to 5 days. Over past two days, developed
vomiting
with hematemesis, reporting multiple episodes of small amounts
of
coffee-ground emesis. No further vomiting here. Reports
significant pain in abdomen. Patient has had numerous
presentations with hematemesis and SBO, seen in ED 5 times this
month often leaving AMA. Recently admitted for L pyelonephritis
with cipro resistant pseudomonas discharged on IV cefepime.
Also has had cough and shortness of breath with wheezing.
Patient
sent for evaluation of small bowel obstruction as well as
concern
for COPD exacerbation.
- In the ED, initial vitals were:
T 98.6 HR 50 BP 149/70 RR 18 SPO2 95% RA
- Exam was notable for:
wheezing symmetric, no respiratory distress, +coughing
abdomen w/ urostomy w/ signs of infection, significant surgical
scars, mildly distended, hypoactive BS, diffusely TTP, maximally
in LLQ
- Labs were notable for:
139 | 107 | 7
----------------< 92 AGap=16
4.3 | 16 | 0.8
WBC 8.7 HGB 11.6 PLT 281
ALT: 12 AP: 106 Tbili: <0.2 Alb: 4.5
AST: 14 LDH: Dbili: TProt:
___: Lip: 69
Trop-T: <0.01
- Studies were notable for:
CT Abd & Pelvis W/O Contrast
1. The stomach is significantly distended. However, no
additional
findings to suggest gastric outlet obstruction.
2. Mild dilation of small bowel at the right mid abdominal
anastomotic site, not out of expected range given postoperative
site. Slightly distal to the anastomosis, there are extremely
decompressed distal small bowel. Significance of extremely
decompressed small-bowel is of questionable clinical
significance
given lack of significant upstream dilatation. The stool
contains
high-density material, presumably from previously ingested
material and a moderate stool burden.
3. New mild left hydronephrosis.
Chest (Portable Ap)
No evidence of an acute cardiopulmonary abnormality.
- The patient was given:
IV Morphine Sulfate 4 mg
IV Famotidine 20 mg
IVF LR ( 1000 mL ordered)
IV Ondansetron 4 mg
IH Ipratropium Bromide Neb 1 NEB
IV Morphine Sulfate 4 mg
TP Lidocaine Jelly 2% (Glydo)
IV Morphine Sulfate 4 mg
IVF LR ( 1000 mL ordered)
- ACS and urology were consulted
ACS: recommend ngt; admit to ___ health service, npo, ivf,
acs
to follow closely
Uro: No indication for acute urologic intervention. Any
operative
intervention for small bowel obstruction will be best managed by
general surgery.
Of note, patient refused NGT placement in the ED.
On arrival to the floor, she reports persistent abdominal pain.
Past Medical History:
- COPD: on home O2 at night, still smoking, multiple
exacerbations yearly, never intubated.
- possible tracheobronchomalacia
- h/o pulmonary embolism, no longer on anticoagulation
- ___
- medical attention-seeking personality traits, possible
factitious disorder per psychiatry
- opiate abuse
- Neurogenic Bladder - s/p ileal conduit ___
- insomnia
- ? h/o of SBO in ___
- Diverticulitis
- gastroparesis
- L Lung nodule followed q6 months
-chronic pain from spinal cord injury
Social History:
___
Family History:
mother died at ___ from Lung CA, emphysema
father died at ___ from CAD, chronic EtOH
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: Not charted on floor
GENERAL: Sitting up in bed speaking to me in no distress
HEENT: R eye deviated externally, pupils equal and reactive,
poor
dentition, moist mucous membranes
CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Somewhat poor air movement, faint wheezes bilaterally,
dry
cough, no increased work of breathing
BACK: Bilateral CVA tenderness
ABDOMEN: Diffuse severe abdominal pain to palpation, soft
abdomen, multiple surgical scars
EXTREMITIES: Warm, no edema
NEUROLOGIC: A+Ox3, no movement or sensation in bilateral lower
extremities
DISCHARGE PHYSICAL EXAM:
===========================
VITALS: Reviewed in POE
GEN: asleep when walked into room, and then when woke up
appeared comfortable
PULM: bilateral end expiratory wheezes, productive sounding
cough
ABD: NABS, soft. When pressed lightly began screaming and
punching the bed. No rebound or guarding
Pertinent Results:
LABS:
=================
___ 08:10AM BLOOD Neuts-67.1 ___ Monos-7.7 Eos-3.3
Baso-0.8 Im ___ AbsNeut-5.84 AbsLymp-1.79 AbsMono-0.67
AbsEos-0.29 AbsBaso-0.07
___ 08:10AM BLOOD Glucose-92 UreaN-7 Creat-0.8 Na-139 K-4.3
Cl-107 HCO3-16* AnGap-16
___ 08:10AM BLOOD ALT-12 AST-14 AlkPhos-106* TotBili-<0.2
IMAGING:
================
CXR
No evidence of an acute cardiopulmonary abnormality.
CT ABD/PELVIS
1. The stomach is significantly distended. However, no
additional findings to
suggest gastric outlet obstruction.
2. Mild dilation of small bowel at the right mid abdominal
anastomotic site,
not out of expected range given postoperative site. Slightly
distal to the
anastomosis, there are extremely decompressed distal small
bowel.
Significance of extremely decompressed small-bowel is of
questionable clinical
significance given lack of significant upstream dilatation. The
stool
contains high-density material, presumably from previously
ingested material
and a moderate stool burden.
3. New mild left hydronephrosis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Shortness of breath
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. TraZODone 100 mg PO QHS
4. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr
transdermal Apply two patches q 72 hours
5. Nicotrol (nicotine) 10 mg inhalation Q4H:PRN Cravings
6. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Discharge Condition:
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough// eval PNA
TECHNIQUE: Frontal view
COMPARISON: Chest radiographs between ___ and ___
FINDINGS:
The lungs are well expanded and clear. No pleural effusion or pneumothorax.
Heart size is normal. The mediastinal silhouette is unremarkable.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with vomiting, no flatus.
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 5.9 s, 46.6 cm; CTDIvol = 14.6 mGy (Body) DLP = 678.3
mGy-cm.
Total DLP (Body) = 678 mGy-cm.
COMPARISON: Prior CT abdomen/pelvis dated ___.
FINDINGS:
LOWER CHEST: Right hemidiaphragmatic elevation, similar to prior.
Emphysematous changes. There is no evidence of pleural or pericardial
effusion. Relative hypoattenuation of the blood pool compared to the
myocardium, suggestive of anemia.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY:Redemonstration of an atrophic left kidney with multiple areas of
scarring. Embolization coils again seen within the left kidney. Mild
hydronephrosis in the left kidney, new compared to prior. The right kidney
appears normal. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is significantly distended. However, no cause
for gastric outlet obstruction. Patient is status post ileal conduit and
urostomy. Mild dilation of the small bowel at the small bowel anastomosis site
with the appearance of a transition point just distal to the anastomosis with
decompressed small bowel distally. The colon contains high-density material
and a moderate stool burden. Of note, oral contrast was administered during
this exam. The appendix is not visualized.
PELVIS: The urinary bladder is decompressed. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Postsurgical changes and right urostomy are seen in the right
anterior abdominal wall.
IMPRESSION:
1. The stomach is significantly distended. However, no additional findings to
suggest gastric outlet obstruction.
2. Mild dilation of small bowel at the right mid abdominal anastomotic site,
not out of expected range given postoperative site. Slightly distal to the
anastomosis, there are extremely decompressed distal small bowel.
Significance of extremely decompressed small-bowel is of questionable clinical
significance given lack of significant upstream dilatation. The stool
contains high-density material, presumably from previously ingested material
and a moderate stool burden.
3. New mild left hydronephrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Coffee ground emesis
Diagnosed with Hematemesis
temperature: 98.6
heartrate: 50.0
resprate: 18.0
o2sat: 95.0
sbp: 149.0
dbp: 70.0
level of pain: 10
level of acuity: 2.0 | ___ transgender male to female with history of
paraplegia
___ MVC, neurogenic bladder s/p ileal conduit + urostomy, PE in
setting of PICC (not on anticoagulation), COPD (on 2L home O2),
pyelonephritis, recurrent SBO, chronic constipation presenting
with hematemesis and constipation/obstipation with imaging
showing dilated stomach who left AMA.
#Dilated stomach w/ possible ileus:
She was initially given IV morphine for her pain. When it was
explained to her that IV opioids exacerbate an ileus and would
make things worse she got dressed to leave. Asked if she would
be willing to stay to receive her discharge paperwork and
prescriptions for medications she said no and left.
# Hydronephrosis
# Ileal conduit
# Recent pyelonephritis
She was seen by urology for her mild L hydronephrosis and they
placed a foley in her urostomy. They recommended she have repeat
renal ultrasound in ___. She left before foley could be
re-evaluated.
#COPD exacerbation:
Her symptoms were consistent with a COPD exacerbation. She was
ordered for prednisone and azithromycin in the hospital. She
declined to wait for prescriptions before leaving. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / carboplatin
Attending: ___.
Chief Complaint:
Scalp numbness
Major Surgical or Invasive Procedure:
Pericardiocentesis with pericardial drain ___
History of Present Illness:
___ is a ___ yo woman with metastatic ovarian cancer
(spine, soft tissue, abdominal/pelvic LAD) progressive through
multiple lines of chemo now on weekly taxol, who presents with 1
day of right scalp paresthesia.
Ms ___ reports she was in her USOH until yesterday evening,
when she took off her wig and then noticed that as she ran her
hand over the right scalp she had paresthesia over this area.
She
states she touches her head every day as she is self conscious
about not having hair and noticed instantly around 6 pm that
something was different. She noticed a "minor" headache that was
relieved in 1 hr after she took her usual oxycontin. The
headache
was over the top of the head and she felt it was so minor she
could not identify any other qualities to this pain. She denied
any vision changes, facial droop, trouble speaking, distal
numbness/tingling/weakness apart from her chronic right thigh
numbness that has been present since development of lymphedema
in
that leg.
She otherwise denies any chest pain, SOB, fevers/chills, cold
symptoms, abdominal pain, diarrhea, constipation. She has had
ongoing back pain at the site of her known L2 lesion without any
bowel/bladder incontinence, saddle anesthesia.
In the ED, vitals were normal. CT head showed multiple subcm
probable parenchymal metastatic lesions with surrounding edema
in
the right parietooccipital lobe, left frontal lobe, and adjacent
to left rectus gyrus. Neurology was consulted and felt that she
was likely symptomatic from newly discovered brain mets. She was
given dexamethasone 4 mg and admitted.
All other review of systems are negative unless stated otherwise
Past Medical History:
- anxiety/depression
ONCOLOGIC HISTORY:
- ___ Underwent optimal debulking with partial bowel
resection
- ___ C1 Paclitaxel 175 mg/m2 IV and Carboplatin 5 AUC IV
- ___ C2 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C3 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C4 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C5 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ C6 Paclitaxel 60 mg/m2 IP, Cisplatin 75 mg/m2 IP, and
Paclitaxel 135 mg/m2 IV
- ___ Started Arimidex for rising CA125
- Persistent rise in CA125 through Arimidex
- ___ C1 Liposomal Doxorubicin 30 mg/m2 IV Carboplatin 5
AUC IV
- ___ C2 Liposomal Doxorubicin 30 mg/m2 IV Carboplatin 5
AUC IV
- ___ C3 Liposomal Doxorubicin IV dose reduced by 17% to 25
mg/m2 for skin rash Carboplatin 5 AUC IV
- ___ C4 Liposomal Doxorubicin IV dose reduced by 33% to 20
mg/m2 for skin toxicity Carboplatin 5 AUC IV
- ___ C5 Carboplatin 5 AUC IV, Doxorubicin held for
toxicity
- ___ C6 Carboplatin 5 AUC IV, Doxorubicin held for
toxicity
- ___ CA-125 15.0
- ___ CA-125 8.6, ___
- ___ CA-125 7.9, ___
- ___ CA-125 27, appears to be recurring around 7 months
after completing carboplatin Doxil
- ___ CT torso no measurable metastatic lesions, possible L
axillary LAD
- ___ CA-125 38
- ___ CA-125 85
- ___ CT torso with increasingly apparent retroperitoneal
and left pelvic sidewall lymph nodes with a rounded morphology,
new since ___, concerning for metastases.
- ___ CA-125 81
- ___ C1D1 Carboplatin 4 AUC D1, gemcitabine 800 mg/m2 D1,___
- ___ C2D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 95
- ___ C3D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 119
- ___ CT torso showed borderline liver lesion and decreased
pelvic LAD
- ___ C4D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 114
- ___ C5D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,8, CA-125 54
- ___ C6D1 Carboplatin 4 AUC D1, bevacizumab 15 mg/m2 D1,
gemcitabine 800 mg/m2 D1,___
- ___ last dose of gemcitibine
- ___ C1 Single agent Avastin 920mg maintainance therapy,
CA-125 16
- ___ C2 Avastin 925mg, CA-125 ___ C3 Avastin 905mg, CA-125 9.8
- ___ C4 Avastin 900mg, CA-125 8.7
- ___ C5 Avastin 900mg, CA-125 9.8
- ___ C6 Avastin 900mg, CA-125 ___
- ___ CA-125 14. Patient signed consent for the ___ trial
___.
- ___ C1D1 Protocol ___ BKM120 plus Olaparib
- ___: CT torso with ___
- multiple CT scans ___ with ___
- ___ -Increased Olaparib to 150mg PO BID due to rising
CA-125
- ___- Increased Olaparib to 200mg BID due to rising
CA-125, and BKM120 40 mg po daily
- ___ CT A/P ? multiple retroperitoneal/paraaortic lymph
nodes are new or increased in size, particularly nodes about
the the origin of the ___, aortic bifurcation and left
paraaortic station suspicious for disease progression"
- ___: Removed from trial ___ for disease
progression; continued olaparib 400mg po bid off trial
- ___: Decreased olaparib to 200mg bid given anemia
- ___: C1D1 Research protocol ___ (varlilumab and
nivolumab)
- ___: Noted to have worsening right supra clavicle
lymphadenopathy and to have upper left-sided back pain at the
level of the upper T-spine around the scapula area. She
underwent restaging scans earlier than planned and this included
a CT of the neck chest abdomen and pelvis on ___ showing
worsening T for osseous metastatic disease which was sclerotic
in nature and present along the lateral aspect.
- ___: XRT to T3-T5
- ___: Rucaparib 400 mg BID initiated
- ___ hospitalizaed with lower extremity edema and
pain.
Lower extremity ultrasound was negative for DVT. She had a CT
abdomen and pelvis which showed new liver lesions, worsening
pelvic lymphadenopathy and retroperitoneal lymphadenopathy,
increased size of pulmonary nodules and right paraspinal soft
tissue mass.
- ___ increased rucaparib to 600 mg BID
- ___ C1 carboplatin
- ___ C2 carboplatin
- ___ C3 carboplatin c/b hypersensitivity reaction
- ___ C4 carboplatin desensitization
- ___ C5 carboplatin desensitization
- ___ hospitalized due to right leg numbness. An MRI
of
the T and L-spine was performed which showed a new metastatic
lesion in the L2 vertebral body. There was also a metastatic,
soft tissue lesion in the right psoas muscle. There was no
evidence of spinal cord compression.
- ___ port removed due to growth of right supraclavicular
node
- ___ radiation to L2-L4 and psoas muscle lesion
- ___ started rucaparib 400 mg BID
- ___ started XRT to right supraclavicular node
- ___ increased rucaparib to 600 mg BID
- ___ hospitalized with bowel obstruction
- ___ C1 Weekly Taxol
- ___ C2 weekly taxol
- ___ C3 Weekly taxol
Social History:
___
Family History:
Family history of breast cancer; three sisters, one deceased
from breast cancer in ___. Family history of diabetes in mother
and sisters.
Physical Exam:
Admission:
General: Well appearing middle aged woman resting in bed
comfortably
Neuro:
- Cranial nerves:
Visual acuity intact in both eyes to finger counting,
visual
fields full,
PERRL (left pupil slightly (~0.5 mm) larger than right when
both dilated and restricted)
EOMI, no nystagmus
Facial sensation intact, reports paresthesia over the right
scalp about 1 inch above the ear
Resists eye opening ___
Hearing intact to finger rub b/l
Palate elevates symmetrically
Tongue midline
Shoulder shrug ___
Motor:
___ handgrip bilaterally
___ hip flexion, knee extension/flexion, plantar and
dorsiflexion
Sensation intact to light touch over UE and ___ except for a
patch
in the anterior right thigh that is chronically numb per patient
from her lymphedema
Alert and oriented, provides clear and crisp history, able to
recall medications and appointments. ___ floor"
HEENT: Oropharynx clear, MMM, no lesions. 1 cm right posterior
cervical node, fixed and nontender. Large right neck mass, firm,
fixed, nontender.
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear bilaterally
Abdomen: Soft, nontender, nondistended. normal bowel sounds
present
Extr/MSK: No pitting edema, R leg larger than left, chronic per
patient from lymphedema
Skin: No notable rashes
Access: L POC not yet accessed. Site c/d/i
Pertinent Results:
Admission:
___ 04:23PM GLUCOSE-100 UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.3* CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
___ 04:23PM estGFR-Using this
___ 04:23PM WBC-4.3 RBC-3.57* HGB-11.0* HCT-34.9 MCV-98
MCH-30.8 MCHC-31.5* RDW-14.3 RDWSD-51.8*
___ 04:23PM NEUTS-71.0 LYMPHS-16.4* MONOS-11.2 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-3.04 AbsLymp-0.70* AbsMono-0.48
AbsEos-0.02* AbsBaso-0.01
___ 04:23PM PLT COUNT-290
___ 04:23PM ___ PTT-26.7 ___
Imaging:
TTE ___:
IMPRESSION: Moderate to large circumferential pericardial
effusion with echocardiographic
evidence of tamponade in the setting of low filling pressures.
Normal left ventricular wall
thickness, cavity size, and regional/global systolic function.
Mild aortic regurgitation.
CT chest w/ contrast ___:
IMPRESSION:
Right axillary adenopathy has significantly increased since the
prior study.
The right supraclavicular nodal mass is unchanged.
No significant interval change in the mediastinal adenopathy and
numerous
bilateral pulmonary metastasis.
Increased pericardial effusion and new bilateral pleural
effusions right
greater than left.
New consolidative opacity in the right paramediastinal region
could be related
to radiation therapy.
Stable sclerotic lesion involving T4 vertebral body.
Multiple hepatic metastasis
___ CT A/P:
IMPRESSION:
1. Slight increase of liver lesions, small right abdominal wall
soft tissue
nodules and iliac nodes.
2. Slightly increased obstructive right hydronephrosis and
hydroureter related
to a pelvic soft tissue nodule or lymph node.
3. Please refer to the separate reports for the CT neck and
chest.
CT neck w/ contrast ___
1. Increased partially necrotic cervical lymphadenopathy,
substantially worse
on the right than on the left.
2. Partially imaged intracranial metastases are better assessed
on same day
brain MRI.
3. Unchanged heterogeneous C2 vertebral body/dens. Difficult to
exclude
metastasis.
4. A 1.3 cm enhancing right thyroid lobe nodule is unchanged.
5. Please refer to separate report for same-day CT chest for
complete
description of the thoracic findings.
MRI head w/o contrast:
1. Evaluation of intracranial metastatic disease is limited in
the absence of
intravenous contrast. However, multiple small cerebral
metastases are
demonstrated bilaterally.
2. Mild edema associated with the right superior occipital
lesion causes
effacement of the atrium of the right lateral ventricle. No
other significant mass effect.
3. Concurrent cervical, thoracic, and lumbar spine MRI is
reported separately.
COMMENT:
According to the MRI technologist, the patient expressed a
willingness to
return for contrast enhanced imaging at another time.
TTE ___
There is normal left ventricular wall thickness with a normal
cavity size. There is normal regional left ventricular systolic
function. There is a small pericardial effusion subtending the
right heart. Stranding is
visualized within the pericardial space c/w organization. There
are no 2D or Doppler echocardiographic evidence of tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
pericardial effusion now much smaller.
MRI Spine:
1. No abnormal enhancement identified within the osseous
metastatic disease.
There is no leptomeningeal metastatic disease.
2. Unchanged fatty marrow replacement of the T2, T3, T5 and L1
through L4
vertebral bodies, possibly a sequela of prior radiation therapy.
3. Stable degenerative changes of the spine, described in detail
in the prior
report.
4. Moderate right and small left pleural effusions. Unchanged
cervical
lymphadenopathy and stable right hydronephrosis and partially
visualized
hydroureter.
MRI Brain:
Multiple enhancing lesions are noted in the supratentorial brain
with a
punctate lesion in the in the right cerebellum. All of the
lesions except 1
are smaller than 1 cm in size. The lesions demonstrate mild
surrounding edema
without midline shift or blood products.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine-Prilocaine 1 Appl TP ONCE
2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. PredniSONE 50 mg PO 1 TABLET(S) BY MOUTH 13 HOURS, 7 HOURS,
AND 1 HOUR PRIOR TO SCAN
4. Magnesium Oxide 400 mg PO DAILY
5. Gabapentin 100 mg PO TID
6. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
7. LORazepam 0.5 mg PO Q6H:PRN nausea, insomnia
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. DiphenhydrAMINE 50 mg PO 1 CAPSULE(S) BY MOUTH 1 HOUR PRIOR
TO SCAN
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
13. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed Disp #*12 Tablet Refills:*0
3. DiphenhydrAMINE 50 mg PO 1 CAPSULE(S) BY MOUTH 1 HOUR PRIOR
TO SCAN
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. Gabapentin 100 mg PO TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lidocaine-Prilocaine 1 Appl TP ONCE
8. Magnesium Oxide 400 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
11. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pericardial effusion
Metastatic ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with stage 4 ovarian cancer w mets presenting w
right occiput numbness.// eval brain mets
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, 16.2 cm; CTDIvol = 49.4 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head ___
FINDINGS:
There is increased focal vasogenic edema in the right parietoccipital region
(02:17) surrounding an approximately 8 mm probable lesion concerning for
metastasis. A couple smaller millimetric probable lesions are seen in the
left frontal lobe with surrounding edema (02: 19, 20). There is another
probable metastatic lesion adjacent to the left rectus gyrus (2:7). There is
no definite acute intracranial hemorrhage or large acute infarct. No evidence
of midline shift. The ventricles and sulci are normal in size and
configuration.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
1. Multiple subcentimeter probable parenchymal metastatic lesions with
surrounding vasogenic edema located in the right parietoccipital region, left
frontal lobe, and adjacent to the left rectus gyrus. No acute intracranial
intracranial hemorrhage or large acute infarct.
RECOMMENDATION(S): A dedicated MRI can be obtained for further evaluation, if
clinically indicated.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with acute right occiput numbness// concern for
IJ clot
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: CT of the neck with contrast from ___
FINDINGS:
Please note this is a limited exam for evaluation of the right internal
jugular vein. The right internal jugular vein appears patent with normal
color flow, spectral Doppler, and compressibility.
Note is made of extensive right cervical lymphadenopathy. For example, the
largest lymph node measures approximately 2.5 x 1.6 x 2.0 cm.
IMPRESSION:
1. Please note this is a limited exam for evaluation of the right internal
jugular vein. No evidence thrombus in the right IJ vein.
2. Cervical lymphadenopathy as seen on recent CT of the neck.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with stage IIIC ovarian cancer with metastatic
recurrence, now presenting with right scalp numbness and found to have new
metastatic brain mets on CT. Evaluation the newly discovered CNS mets seen on
recent CT.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained. Intravenous contrast was not administered, and contrast enhanced
imaging was not performed as the patient was not able to tolerate further
imaging at this time.
COMPARISON Head CT from ___.
FINDINGS:
Multiple rounded, well-circumscribed lesions with surrounding edema are likely
compatible with metastases. There is approximately 7 mm lesion in the right
superior occipital lobe with mild surrounding edema (08:12) and mild
effacement of the atrium of the right lateral ventricle, and a smaller
adjacent subcortical a posterior occipital lesion on image 8:12. Subcentimeter
lesions with mild surrounding edema are seen in the bilateral frontal centrum
semiovale, left frontal gray/white matter junction, and right parietal
gray/white matter junction on image 8:17. There is an approximately 5 mm
lesion in the supraorbital left frontal lobe with surrounding edema (08:10).
A smaller focus of edema is seen along the posterior left gyrus rectus (8:9).
There are additional smaller foci of T2/FLAIR hyperintensity in the right
corona radiata and left putamen on images ___, left posterior temporal
white matter on image 8:10, and other small white matter lesions, which may
reflect metastases versus small vessel ischemic changes.
Some of the lesions demonstrate high signal on diffusion-weighted images,
suggesting hypercellularity.
Other than the mild effacement of the atrium of the right lateral ventricle,
there is no significant mass effect. Other components of the ventricular
system are normal in size. Basal cisterns are normal in size. No shift of
midline structures.
Allowing for the previously demonstrated small caliber of the intracranial
right vertebral artery, major vascular flow voids appear grossly preserved.
Known metastatic lesion involving the odontoid process and vertebral body of
C2 is better assessed on the concurrent spine MRI.
There is mild mucosal thickening in the ethmoid, frontal, and maxillary
sinuses.
IMPRESSION:
1. Evaluation of intracranial metastatic disease is limited in the absence of
intravenous contrast. However, multiple small cerebral metastases are
demonstrated bilaterally.
2. Mild edema associated with the right superior occipital lesion causes
effacement of the atrium of the right lateral ventricle. No other significant
mass effect.
3. Concurrent cervical, thoracic, and lumbar spine MRI is reported separately.
COMMENT:
According to the MRI technologist, the patient expressed a willingness to
return for contrast enhanced imaging at another time.
Radiology Report
INDICATION: ___ year old woman with stage IIIC ovarian cancer with metastatic
recurrence, now presenting with right scalp numbness and found to have new
metastatic brain lesions. Evaluate for spinal disease, especially right C2
lesion. Evaluate for metastatic CNS disease. Review of prior imaging studies
reveals that the patient has known osseous metastases in the cervical,
thoracic, and lumbar spine.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and IDEAL images of the
cervical, thoracic, and lumbar spine spine with axial T2 weighted images.
Intravenous contrast was not administered, and postcontrast imaging was not
performed, because the patient was not able to tolerate further imaging.
COMPARISON: Cervical spine MRI from ___
Thoracic and lumbar spine MRI from ___
Soft tissue neck CT from ___
CT abdomen pelvis from ___
CT chest from ___
FINDINGS:
There are 7 cervical, 12 rib-bearing, and 5 lumbar-type vertebrae.
CERVICAL:
The level of C1 is suboptimally assessed on the sagittal images due to motion
artifact. The previously noted T1 and T2 hypointense lesion, with sclerosis
on CT, in the right aspect of the odontoid and right greater than left body of
C2, appears similar in extent to the most recent neck CT from ___, with slightly increased involvement of the left aspect of the C2
vertebral body compared to both the neck CT from ___ and cervical
spine MRI from ___. This remains most compatible with a treated
metastasis, though postcontrast imaging would be needed to assess for any new
contrast enhancement. Within the limits of noncontrast MRI, there is no
evidence for epidural or neural foraminal extension.
No new cervical osseous lesion is identified. Within the limits of
noncontrast MRI, no evidence for an epidural mass. Spinal cord signal appears
normal without evidence for edema. However, contrast enhanced images would be
needed to assess for leptomeningeal seeding.
Vertebral body heights are preserved. Minimal retrolisthesis of C5 on C6 is
unchanged. Multilevel cervical degenerative disease appears similar to the ___ cervical spine MRI, allowing for motion artifact on the present axial
images.
C2-C3: No spinal canal narrowing. Mild left neural foraminal narrowing by
uncovertebral and facet osteophytes.
C3-C4: Broad-based central disc protrusion and endplate osteophytes minimally
indent the ventral thecal sac without significant spinal canal narrowing.
Severe right and moderate left neural foraminal narrowing by uncovertebral and
facet osteophytes.
C4-C5: Broad-based central disc protrusion endplate osteophytes minimally
indent the ventral thecal sac without significant spinal canal narrowing.
Moderate left neural foraminal narrowing by uncovertebral and facet
osteophytes.
C5-C6: Broad-based central disc protrusion, slightly larger on the left than
right, without significant spinal canal narrowing. Severe right and moderate
left neural foraminal narrowing by uncovertebral and facet osteophytes.
C6-C7: No significant spinal canal narrowing. Moderate right and
mild-to-moderate left neural foraminal narrowing by uncovertebral and facet
osteophytes.
C7-T1: No significant spinal canal or neural foraminal narrowing.
THORACIC:
Axial T2 weighted images are substantially limited by motion artifact.
The lesion in the left vertebral body and left pedicle of T4 appears stable in
extent and appearance compared to the MRI from ___, with low T1
signal and heterogenous T2 signal, and sclerosis on the neck CT from ___. This remains most compatible with a treated metastasis, though
postcontrast imaging would be needed to assess for any new contrast
enhancement. Within the limits of noncontrast MRI, there is no evidence for
epidural or neural foraminal extension.
Fatty marrow replacement is again seen in the T 2, T3, and T5 vertebral body,
suggesting sequela of radiation therapy. No new thoracic osseous lesion is
identified. Within the limits of noncontrast MRI, no evidence for an epidural
mass. No cord edema or other cord signal abnormalities are seen on sagittal
T2 weighted images; axial images are limited by motion artifacts. Contrast
enhanced images would be needed to assess for leptomeningeal seeding.
No significant thoracic spinal canal narrowing.
LUMBAR:
The previously seen T1 hypointense and predominantly T2 hypointense lesion in
the right anterior aspect of L2 vertebral body, with sclerosis on the
abdominal/pelvic CT from ___, appears slightly smaller compared to
the MRI from ___, images 14:17, 11:13.
However, there are two new small T1 and T2 hypointense foci along the inferior
endplate of L2 compared to ___, measuring 2 mm anteriorly on image
11:8 and 3 mm posteriorly on image 11:9. T2 hypointensity and absence of
correlates on the CT from ___ are concerning for metastases rather
than Schmorl's nodes.
Within the limits of noncontrast MRI, no evidence for an epidural mass. The
conus medullaris demonstrates normal morphology and signal intensity on
sagittal T2 weighted images, terminating at L1. Contrast enhanced images
would be needed to assess for leptomeningeal seeding.
From T12-L1 through L1-L 2, there is no significant spinal canal or neural
foraminal narrowing.
At L3-L4, there is a mild disc bulge and facet arthropathy without significant
spinal canal or neural foraminal narrowing.
At L4-L5, there is a mild disc bulge, moderate right and severe left facet
arthropathy. Traversing L5 nerve roots are contacted in the subarticular
zones. The thecal sac is mildly narrowed without mass effect on the
intrathecal nerve roots. Moderate bilateral neural foraminal narrowing with
abutment of the exiting L4 nerve roots.
At L5-S1, there is a mild disc bulge and moderate facet arthropathy.
Subarticular zones are mildly narrowed. Moderate bilateral neural foraminal
narrowing with abutment of the exiting L5 nerve roots.
OTHER:
Right cervical lymphadenopathy is again seen involving levels 2 through 5,
slightly difficult to compared to the ___ soft tissue neck CT due
to differences in the angle of the axial images. The largest visualized lymph
node between levels 2 and 3 measures 2.0 cm in long axis on image 7:16
compared to 1.6 cm on ___.
There is a right pleural effusion, probably slightly increased compared to the
last chest CT from ___ though comparison is limited by
differences in modalities. The pulmonary consolidation at the right apex seen
on the neck CT from ___ is again partially imaged, image 12:15.
Previously seen pulmonary nodules are not adequately reassessed on this exam.
Right hydronephrosis and partially imaged right hydroureter similar to the ___ abdominal/pelvic CT. 5 mm T2 hyperintense lesions in the lower
pole of the right kidney on image 14:22 and in the lower pole of the left
kidney on image 14:20 are unchanged, statistically likely cysts.
IMPRESSION:
1. Incomplete exam without intravenous contrast. Contrast enhanced imaging
was not obtained as the patient was not able to tolerate further imaging.
Furthermore, axial images are limited by motion artifact.
2. T1 hypointense, sclerotic lesions involving C2 vertebral body and the
odontoid, and T4 left vertebral body/pedicle, appear unchanged compared to the
neck CT from ___ and thoracic spine MRI from ___,
respectively. The C2 lesion is slightly larger than on the cervical spine MRI
from ___. These remain consistent with treated metastases, though
contrast enhanced imaging would be needed to assess for any active contrast
enhancement.
3. T1 hypointense, sclerotic lesion involving the right anterior L2 vertebral
body appears smaller than on ___. However, new 2 mm and 3 mm T1
hypointense foci in the L2 inferior endplate are concerning for new
metastases.
4. Within the limits of noncontrast MRI, there is no evidence for epidural
metastatic disease. The spinal cord demonstrates normal morphology and signal
intensity, but contrast enhanced imaging is needed to assess for
leptomeningeal seeding.
5. Degenerative changes in the cervical and lumbar spine are similar to prior
studies.
6. Right cervical lymphadenopathy is difficult to compared to the ___ soft tissue neck CT due to differences in the angle of the axial images.
Mild enlargement cannot be excluded.
7. Partially imaged right pleural effusion appears slightly increased compared
to the last chest CT from ___ though comparison is limited by
differences in modalities. Previously seen pulmonary consolidation at the
right apex is again partially visualized. Previously seen pulmonary nodules
are not adequately reassessed on this exam.
8. Right hydronephrosis is similar to CT abdomen from ___. Right
hydroureter is again partially imaged.
COMMENT:
According to the MRI technologist, the patient expressed a willingness to
return at another time for contrast enhanced imaging.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with known metastatic ovarian cancer presenting
with new brain mets, outpatient oncology requesting this scan for metastatic
disease// evidence of metastatic disease
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen was done with IV
contrast. A single bolus of IV contrast was injected and the abdomen and
pelvis was scanned in the portal venous phase, followed by scan of the abdomen
in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 8.7 s, 0.2 cm; CTDIvol = 148.4 mGy (Body) DLP =
29.7 mGy-cm.
3) Spiral Acquisition 10.1 s, 65.4 cm; CTDIvol = 9.2 mGy (Body) DLP = 593.7
mGy-cm.
4) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 8.9 mGy (Body) DLP = 268.1
mGy-cm.
Total DLP (Body) = 893 mGy-cm.
COMPARISON: Previous CT from ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation. There has been
minimal size increase in many of the hypodense lesions, while some of the
smaller lesions have not significantly changed. For example, the largest
lesion in segment 8 (05:50) measures 2.3 x 2.1 cm, previously 1.9 x 1.9 cm
using similar measurement technique. No new lesions are identified. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is contracted but grossly unremarkable.
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 right kidney demonstrates slightly increased moderate
hydronephrosis and a delayed nephrogram. There is hydroureter down to the
level of a 2.1 x 1.3 cm right pelvic soft tissue mass or lymph node, which is
stable. The left kidney is unremarkable aside from small subcentimeter
cortical hypodensities, likely cysts. There is no left hydronephrosis or
hydroureter.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There has been
prior ileocecal resection with ileocolic anastomosis as well as rectosigmoid
resection with reanastomosis. Residual large bowel is unremarkable.
PELVIS: The bladder is grossly unremarkable. The right distal ureter appears
obstructed by a soft tissue mass as noted above. The left distal ureter is
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post TAH/BSO.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A
stable right external inguinal node measures 2.5 x 2.0 cm. A 1.1 cm right
inguinal node is also stable. A left external iliac node (5:102) measures 9
mm, previously 5 mm and right common iliac node (5:86) measures 1.2 cm,
previously 8 mm.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Retroperitoneal soft tissue nodules measuring up to 1.4 cm on
the right (5:77) and 5 mm on the left (5:80) are stable. A soft tissue nodule
in the right posterior abdominal wall adjacent to the paraspinal muscles
(5:77) measures 8 mm, previously 5 mm. Two intramuscular enhancing nodules in
the right posterior abdominal wall (5:70, 72) measures 8 and 13 mm, previously
5 and 10 mm.
IMPRESSION:
1. Slight increase of liver lesions, small right abdominal wall soft tissue
nodules and iliac nodes.
2. Slightly increased obstructive right hydronephrosis and hydroureter related
to a pelvic soft tissue nodule or lymph node.
3. Please refer to the separate reports for the CT neck and chest.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with known metastatic ovarian cancer presenting
with new brain mets and ongoing neck pain, outpatient oncology requesting this
scan for metastatic disease// evidence of metastatic disease, any fractures or
bony disease
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 26.6 cm; CTDIvol = 7.1 mGy (Body) DLP = 183.1
mGy-cm.
Total DLP (Body) = 183 mGy-cm.
COMPARISON:
1. Same day brain MRI and chest CT
2. ___ neck CT
FINDINGS:
There is extensive partially necrotic right greater than left cervical
lymphadenopathy. Confluent adenopathy at levels 2 and 3 on the right measures
up to 3.5 x 1.4 x 5.8 cm, significantly increased since the prior examination
(series 3, image 39; series 6, image 33). A right level Va lymph node
measures 1.4 cm, previously 0.7 cm. A representative left level IIa lymph
node measures 9 mm, previously 6 mm. Representative left level IV lymph nodes
measure up to 1.0 cm, previously 1.0 cm.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect. The salivary glands enhance normally and are without mass
or adjacent fat stranding.The neck vessels are patent.
A 1.3 cm right enhancing thyroid lobe nodule is unchanged. Please refer to
separate report for same-day CT chest for complete description of the thoracic
findings.
A partially imaged left frontal lobe lesion measures 6 mm (series 3, image 2).
There is mild adjacent vasogenic edema, better characterized on same day brain
MRI. A right temporal lobe lesion measures 5 mm (series 3, image 6).
Unchanged heterogeneous C2 vertebral body/dens. Difficult to exclude
metastasis.
IMPRESSION:
1. Increased partially necrotic cervical lymphadenopathy, substantially worse
on the right than on the left.
2. Partially imaged intracranial metastases are better assessed on same day
brain MRI.
3. Unchanged heterogeneous C2 vertebral body/dens. Difficult to exclude
metastasis.
4. A 1.3 cm enhancing right thyroid lobe nodule is unchanged.
5. Please refer to separate report for same-day CT chest for complete
description of the thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with known metastatic ovarian cancer presenting
with new brain mets, outpatient oncology requesting this scan for metastatic
disease// evidence of metastatic disease
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 8.7 s, 0.2 cm; CTDIvol = 148.4 mGy (Body) DLP =
29.7 mGy-cm.
3) Spiral Acquisition 10.1 s, 65.4 cm; CTDIvol = 9.2 mGy (Body) DLP = 593.7
mGy-cm.
4) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 8.9 mGy (Body) DLP = 268.1
mGy-cm.
Total DLP (Body) = 893 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: To a prior study done on ___
FINDINGS:
THORACIC INLET: There is a left-sided Port-A-Cath with its tip in the SVC.
The right supraclavicular nodal mass is unchanged. Please refer to dedicated
report on neck which has been dictated separately
BREAST AND AXILLA : The right axillary lymph nodes have significantly
increased in size since the prior study the largest now measuring 20 mm.
There is stable skin thickening overlying the right breast with evidence of
nodularity, concerning for involvement by tumor (5, 30).
MEDIASTINUM: Incidental note is made of an aberrant right subclavian artery.
There is a moderate-sized pericardial effusion, new since the prior study,
pericardial tamponade cannot be excluded. There are small mediastinal lymph
nodes, also new since the prior study. The right paratracheal lymph node
measures 12 mm the right hilar node measures 19 mm.
PLEURA: There are new bilateral pleural effusions right greater than left, the
effusions are small volume.
LUNG: Consolidative opacity in the right paramediastinal region is new since
the prior study and could represent post radiation changes. There are
numerous bilateral pulmonary metastasis ranging in size from 2 mm to 12 mm.
There is subsegmental atelectasis within the left lower lobe and the right
lower lobe.
BONES AND CHEST WALL : Review of bones shows a sclerotic lesion involving T4
vertebral body, unchanged consistent with known metastasis
UPPER ABDOMEN: Limited sections through the upper abdomen shows multiple
hepatic metastasis. Please refer to a dedicated report on abdomen which has
been dictated separately.
IMPRESSION:
Right axillary adenopathy has significantly increased since the prior study.
The right supraclavicular nodal mass is unchanged.
No significant interval change in the mediastinal adenopathy and numerous
bilateral pulmonary metastasis.
Increased pericardial effusion and new bilateral pleural effusions right
greater than left.
New consolidative opacity in the right paramediastinal region could be related
to radiation therapy.
Stable sclerotic lesion involving T4 vertebral body.
Multiple hepatic metastasis
Please refer to dedicated report on the abdomen and neck for further details.
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST
INDICATION: ___ year old woman with metastatic ovarian cancer, new lesions in
brain// evaluation for whole brain radiation therapy
TECHNIQUE: Axial T1 and MPRAGE post gadolinium images were obtained with
surface markers for surgical planning. FLAIR T2 and susceptibility images of
the brain were also acquired.
COMPARISON: Previous noncontrast brain MRI study of ___.
FINDINGS:
Multiple enhancing brain lesions are identified in both cerebral hemispheres
with the largest lesion measuring 1 cm in the left posterior frontal lobe and
demonstrating rim enhancement. The remaining lesions are smaller than 1 cm in
size. A punctate lesion is also seen within the right cerebellum. None of
the lesions demonstrate blood products. Mild surrounding edema is seen about
the lesion seen centrum semiovale left frontal lobe right occipital lobe. No
definite signs of leptomeningeal enhancement are seen. There is no midline
shift or hydrocephalus.
IMPRESSION:
Multiple enhancing lesions are noted in the supratentorial brain with a
punctate lesion in the in the right cerebellum. All of the lesions except 1
are smaller than 1 cm in size. The lesions demonstrate mild surrounding edema
without midline shift or blood products.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old woman with metastatic ovarian cancer, new lesions in
brain// staging for chemo initiation staging for chemo initiation
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 ___ contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: CT neck from ___ and ___. MRI of the
total spine from ___.
FINDINGS:
CERVICAL:
Sclerotic lesions involving the C2 vertebral body is unchanged and consistent
with treated metastasis. No definitive abnormal contrast enhancement
identified.
The spinal cord is normal in size and configuration. No evidence of abnormal
enhancement.
Degenerative changes of the cervical spine are unchanged from the prior MRI
and described in detail on the prior report.
THORACIC:
Fatty marrow replacement is again seen in the T2, T3 and T5 vertebral bodies,
likely a sequela of prior radiation therapy.
Sclerotic lesion involving the T4 vertebral body and pedicle is unchanged and
consistent with treated metastasis. No abnormal enhancement identified.
The spinal cord is normal in size and configuration. No evidence of abnormal
enhancement.
Degenerative changes of the thoracic spine are unchanged from the prior MRI
and described in detail on the prior report.
LUMBAR:
Fatty replacement of the L1, L 2, L3 and L4 vertebral bodies is again
identified and could reflect a sequela of prior radiation treatment.
Stable small sclerotic lesion along the right aspect of the L2 vertebral body
without abnormal enhancement. No abnormal enhancement along the newly seen T1
and T2 hypointense foci along the inferior endplate of the L2 vertebral body.
The spinal cord is normal in size and configuration. No evidence of abnormal
enhancement. The conus terminates normally at the L1 level.
Degenerative changes of the lumbar spine are unchanged from the prior MRI and
described in detail in the prior report.
OTHER: Moderate right and small left pleural effusions. Unchanged right
cervical lymphadenopathy. Stable right hydronephrosis and partially imaged
hydroureter.
IMPRESSION:
1. No abnormal enhancement identified within the osseous metastatic disease.
There is no leptomeningeal metastatic disease.
2. Unchanged fatty marrow replacement of the T2, T3, T5 and L1 through L4
vertebral bodies, possibly a sequela of prior radiation therapy.
3. Stable degenerative changes of the spine, described in detail in the prior
report.
4. Moderate right and small left pleural effusions. Unchanged cervical
lymphadenopathy and stable right hydronephrosis and partially visualized
hydroureter.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: R Numbness
Diagnosed with Anesthesia of skin, Secondary malignant neoplasm of brain
temperature: 97.8
heartrate: 97.0
resprate: 14.0
o2sat: 96.0
sbp: 138.0
dbp: 96.0
level of pain: 8
level of acuity: 2.0 | ___ with metastatic ovarian cancer (spine, soft tissue,
abdominal/pelvic LAD) progressive through multiple lines of
chemo now on weekly taxol, who presents with 1 day of right
scalp paresthesia and now found to have multiple intracranial
lesions
concerning for new brain metastases.
CCU COURSE
=================
#Pericardial effusion, cardiac tamponade
#Pleural effusions: Found incidentally on imaging during staging
imaging tests. Underwent pericardioentesis with pericardial
drain placement on ___ and was transferred to the CCU while
pericardial drain was in place. Her drain initially put out
420cc of straw color fluid. A repeat TTE on ___ showed
residual small pericardial effusion. The drain was removed on
___ when it had put out 50cc during one shift. Cytology on
the fluid was consistent with metastatic adenocarcinoma of
Mullerian origin. MRI remonstrated small bilateral effusions as
well, but these are not causing the patient symptoms nor
hypoxemia.
==================
# Multiple intracranial lesions with surrounding edema c/f new
brain metastases: Evaluated by neuro-onc, recommended decreased
dose of steroids, now on 4 mg daily of dexamethasone which she
will continue. MRI Brain and spine was completed which showed
numerous brain lesions and affected right cervical lymph nodes.
Mapping was completed on ___, and the patient will start
radiation therapy on ___ at ___ with 10 total treatments
planned. Memantine and Ativan were prescribed by radiation
oncology. Continue dexamethasone 4 daily. Literature does not
support ulcer prophylaxis outside of the ICU
# Metastatic ovarian cancer s/p multiple lines of chemotherapy
now on weekly taxol (last given ___
# Cancer associated pain
# RLE lymphedema, numbness: currently relatively comfortable on
home regimen (below). CT torso and neck showing above findings
including necrotic lymph nodes, new L2 lesions concerning for
mets. Dr. ___ (oncology team) aware, will continue to
follow. Continue oxycontin 10 mg BID, oxycodone as needed, and
gabapentin
# Hypomagnesemia: Continue home supplementation
Ms. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of Afib (on eliquis and atenolol) and recent
L
total knee replacement on ___, who presents with dyspnea,
cough, ___ edema, and serous fluid drainage from L knee incision
x3 days.
Mr. ___ was in his usual state of health until ___,
when he underwent L total knee replacement at ___ (Dr. ___.
His course was reportedly complicated by post-operative ileus,
urinary retention, and ___ edema. His pain was well-controlled
with Tylenol and he was discharged home with services on ___.
He initially improved after discharge, was able to ambulate with
assistance of a walker, and felt well. However, two days prior
to
presentation he developed worsening ___ edema (L > R), watery
diarrhea, and abdominal discomfort. The next day, ___,
he also developed shortness of breath and cough productive of
whitish sputum. He reports that although he normally has no
difficulty lying flat in bed, he needed to use a recliner to
prop
himself up in order to sleep over the last few days. Initially,
post-operatively, he had urinary retention. This improved, until
two days prior to presentation, when he again noted retention,
and awoke ___ times per night to try and void but describes it
as
a "dribble." He denies any chest pain, palpitations,
lightheadedness, dizziness, fevers, chills, myalgias, or sweats.
He reports no blood in stool.
Of note, patient and his wife report that his L knee has had
persistent clear to pink-tinged fluid draining from the inferior
portion of his incision bandage. No increased pain, erythema,
pustular discharge, blood, or increased bruising.
Additionally, in ___, Mr. ___ presented to an
urgent care ___ after a fall with head-strike and lacerations
to lower extremities and was found to have cellulitis for which
he was prescribed clindamycin (7 days).
Past Medical History:
- HTN
- osteoarthritis s/p R and L knee arthroplasty
Cardiac Hx:
- Recent nuclear stress test (___) normal with normal systolic
function
- Afib (on eliquis and atenolol)
- Colon polyps (declines further colonoscopies)
- Elevated PSA (has declined further work-up due to age).
Social History:
___
Family History:
Mother had MI in her late ___ and father died of heart failure
in
his late ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: BP 159/94 HR 85 RR 18 ___ on RA
GENERAL: Alert and interactive. Showing off a strong sense of
humor in presence of his immediately family members.
___, atraumatic. Pupils round and reactive to
light with consensual response.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Irregularly irregular rhythm. No extra heart sounds. No
JVD. Non-displaced PMI.
LUNGS: Inspiratory/expiratory wheezing bilaterally in upper and
lower lung fields. Diminished breath sounds at bases. No
crackles.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds. Protuberant abdomen.
Non-distended, non-tender to deep palpation in all four
quadrants. No organomegaly. No fluid wave.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash. Skin tags over torso.
Stasis
dermatitis in lower extremities bilaterally.
NEUROLOGIC: CN2-12 intact. 4+/5 strength in at L knee with ace
bandage on. Able to stand on his own. Favors left leg with gait.
Normal sensation throughout.
DISCHARGE EXAM:
===============
VITALS: ___ ___ Temp: 97.4 PO BP: 125/78 L Lying HR: 78
RR:
18 O2 sat: 94% O2 delivery: RA
WEIGHT: 111.99kg --> 111.45kg yesterday
I/Os: 820cc/1600cc/-780cc overall
GENERAL: Well-appearing gentleman, sitting in bed comfortably,
using a nebulizer
___: NC/AT, EOMI, anicteric sclera
HEART: Irregularly irregular rhythm, regular rate, normal S1/S2,
no m/r/g
LUNGS: Course breath sounds bilaterally, few scattered wheezes,
breathing comfortably without use of accessory mm
ABDOMEN: Somewhat distended, soft, active bowel sounds, no
tenderness to palpation
EXTREMITIES: Trace pitting edema in ___ extremities to knees, L
knee incision c/d/i, no pain with active or passive ROM in L
knee
Pertinent Results:
ADMISSION LABS:
===============
___ 10:48AM ___ PTT-32.4 ___
___ 10:48AM PLT COUNT-156
___ 10:48AM NEUTS-77.4* LYMPHS-5.3* MONOS-14.8* EOS-0.8*
BASOS-0.4 IM ___ AbsNeut-5.52 AbsLymp-0.38* AbsMono-1.06*
AbsEos-0.06 AbsBaso-0.03
___ 10:48AM WBC-7.1 RBC-3.64* HGB-11.2* HCT-34.3* MCV-94
MCH-30.8 MCHC-32.7 RDW-12.9 RDWSD-44.6
___ 10:48AM proBNP-5357*
___ 10:48AM cTropnT-<0.01
___ 10:48AM estGFR-Using this
___ 10:48AM GLUCOSE-111* UREA N-19 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-29 ANION GAP-15
___ 11:49AM URINE MUCOUS-OCC*
___ 11:49AM URINE RBC-2 WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 11:49AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:49AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:49AM URINE UHOLD-HOLD
___ 11:49AM URINE HOURS-RANDOM
___ 04:56PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.5
MAGNESIUM-1.8
___ 04:56PM cTropnT-<0.01
___ 04:56PM ALT(SGPT)-15 AST(SGOT)-22 LD(LDH)-216 ALK
PHOS-68 TOT BILI-1.2
MICROBIOLOGY:
=============
___ 11:49 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:57 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) AT
20:55 ON
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ BLOOD CX: Pending
___ 5:37 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
SERRATIA MARCESCENS. >100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/DIAGNOSTICS:
====================
___ CXR:
Cardiomegaly, pulmonary vascular congestion, and likely mild
pulmonary edema.
No focal consolidation to suggest pneumonia.
___ KNEE XR:
1. Post left total knee arthroplasty without evidence of
hardware complication.
2. Large suprapatellar joint effusion.
3. Possible heterotopic ossification lateral to the knee joint
as above.
___ ECHO:
The left atrial volume index is mildly increased. The right
atrium is moderately dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated
with moderate global hypokinesis (biplane LVEF = 35 %). Systolic
function of apical segments is relatively preserved. The
estimated cardiac index is depressed (<2.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta and aortic arch are mildly dilated. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild to moderate (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with global free wall hypokinesis in a pattern most c/w
a non-ischemic cardiomyopathy. Severe pulmonary arterys systolic
hypertension. Mild-moderate mitral regurgitation. Mild aortic
regurgitation. Mildly dilated thoracic aorta.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
___ CXR:
In comparison with the study of ___, the cardiomediastinal
silhouette is stable. There again is engorgement of indistinct
pulmonary vessels consistent with fluid overload. No evidence
of acute focal pneumonia or pleural effusion.
DISCHARGE LABS:
===============
___ 10:51AM BLOOD WBC-12.7* RBC-4.27* Hgb-12.9* Hct-39.5*
MCV-93 MCH-30.2 MCHC-32.7 RDW-12.9 RDWSD-43.6 Plt ___
___ 10:51AM BLOOD Plt ___
___ 10:51AM BLOOD Glucose-166* UreaN-34* Creat-1.3* Na-141
K-3.7 Cl-94* HCO___-35* AnGap-12
___ 10:51AM BLOOD Calcium-9.9 Phos-2.8 Mg-1.9
Radiology Report
INDICATION: History: ___ with afib, p/w dyspnea and cough// productive cough,
dyspnea, hypoxemia, any acute process
TECHNIQUE: Chest AP and lateral
COMPARISON: None
FINDINGS:
Lungs are moderately well expanded. There is no focal consolidation. Cardiac
silhouette is enlarged. There is pulmonary vascular congestion and likely
mild pulmonary edema. Prominent hila may suggest vascular enlargement. No
pneumothorax or pleural effusion.
IMPRESSION:
Cardiomegaly, pulmonary vascular congestion, and likely mild pulmonary edema.
No focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ post knee replacement with increased pain//
evaluate hardware evaluate hardware
TECHNIQUE: Frontal, lateral, and oblique radiographs of left knee
COMPARISON: Right knee radiographs from ___.
FINDINGS:
The patient is post recent left total knee arthroplasty with hardware in
expected alignment. No evidence of hardware complication. Expected
postsurgical changes include subcutaneous emphysema and soft tissue swelling.
A suprapatellar joint effusion is large. A superior patellar enthesophyte is
small. No fracture or dislocation is seen. No unexplained radiopaque foreign
body.
Ovoid corticated density measuring 2.1 x 1.4 cm projects lateral to the knee
joint, possibly heterotopic ossification or sequela of prior injury.
IMPRESSION:
1. Post left total knee arthroplasty without evidence of hardware
complication.
2. Large suprapatellar joint effusion.
3. Possible heterotopic ossification lateral to the knee joint as above.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with ___ swelling// Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Lower extremity ultrasound from ___
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: CHEST (PORTABLE AP)
INDICATION: ___ year old man with COPD, HFpEF with severe wheezing and
hypoxia// please evaluate for fluid overload
IMPRESSION:
In comparison with the study of ___, the cardiomediastinal silhouette is
stable. There again is engorgement of indistinct pulmonary vessels consistent
with fluid overload. No evidence of acute focal pneumonia or pleural
effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with Fluid overload, unspecified, Dyspnea, unspecified
temperature: 98.5
heartrate: 88.0
resprate: 20.0
o2sat: 98.0
sbp: 167.0
dbp: 94.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is an ___ with PMH of atrial fibrillation (on
apixaban) and recent L total knee replacement at NEB presenting
from home with orthopnea, concerning for acute heart failure
exacerbation, found to have newly reduced ejection fraction on
echo, likely related to tachyarrhythmia and/or stress
cardiomyopathy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
___ Complaint:
Jaw Swelling
Major Surgical or Invasive Procedure:
Incision and Drainage of right submandibular, sublingual and
submental space abscess and hematoma
History of Present Illness:
Mr. ___ is a ___ gentleman with a past medical history
of type 2 diabetes, hypertension, CKD, gout, possible CLL/SLL
vs. mantle cell lymphoma (based on recent CBC at ___'s office)
s/p recent dental procedure who presented to the ED with
swelling and tenderness at the floor of his mouth and in the
sublingual and submental regions. Per patient's son, he had the
bottom portion of his dentures removed surgically three days
prior to admission. Yesterday, he developed pain and swelling of
his mouth/neck, which progressed today. He had difficulty
handling secretions but denied shortness of breath or dysphagia.
He reported chills though no fevers.
Past Medical History:
GOUT
DIABETES TYPE II
HYPERCHOLESTEROLEMIA
HYPERTENSION
CHRONIC KIDNEY DISEASE
Social History:
___
Family History:
Unavailable
Physical Exam:
===================
ADMISSION EXAM
===================
VITALS: T 103, HR 78, BP 122/61 (--> 82/45), SpO2 100% FiO2 0.3
GENERAL: Intubated, arousable to voice
HEENT: PERRL, dry mucous membranes
NECK: Large swelling anteriorly, clean/dry dressing in place
LUNGS: Clear anteriorly, mechanical breath sounds
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
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: Diaphoretic
NEURO: Sedated, arousable to voice, not following commands
===================
DISCHARGE EXAM
===================
Vitals: 97.7, 133/76, 71, 17 97% Ra
General: A&Ox3, NAD
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD, motion limited by
surgical dressing on jaw, small amount of purulent drainage on
dressing changed this morning ___ after drain removal.
Lungs: CTAB, no wheezes, rales, rhonchi, breathing comfortably
on RA
CV: RRR, 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, No swelling or erythema of ankles.
Neuro: CNs2-12 intact, motor function grossly normal
EOE: Submental and submandibular incision sites hemostatic, soft
and mildly tender to palpation, no purulence expressed on
palpation
IOE: FOM mildly elevated and tender to palpation, mandibular
arch
edentulous, no sign of purulence on palpation, implant site # 27
healing appropriately, implant # 22 non-mobile and non-tender
Pertinent Results:
==================
ADMISSION LABS
==================
___ 10:00PM TYPE-ART PO2-172* PCO2-40 PH-7.39 TOTAL
CO2-25 BASE XS-0
___ 10:00PM LACTATE-0.9
___ 09:52PM GLUCOSE-163* UREA N-29* CREAT-1.9* SODIUM-134
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-19
___ 09:52PM CALCIUM-7.7* PHOSPHATE-2.7 MAGNESIUM-1.6
___ 09:52PM WBC-12.4* RBC-4.66 HGB-13.8 HCT-42.1 MCV-90
MCH-29.6 MCHC-32.8 RDW-13.4 RDWSD-44.4
___ 09:52PM PLT COUNT-153
___ 05:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:10PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:10PM URINE MUCOUS-RARE
___ 01:35PM LACTATE-1.4
___ 01:20PM GLUCOSE-197* UREA N-26* CREAT-1.9* SODIUM-135
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-28 ANION GAP-19
___ 01:20PM estGFR-Using this
___ 01:20PM CALCIUM-9.2 PHOSPHATE-2.5* MAGNESIUM-1.9
___ 01:20PM WBC-12.6* RBC-5.27 HGB-15.4 HCT-47.7 MCV-91
MCH-29.2 MCHC-32.3 RDW-13.2 RDWSD-43.7
___ 01:20PM NEUTS-87* BANDS-0 LYMPHS-5* MONOS-8 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-10.96* AbsLymp-0.63*
AbsMono-1.01* AbsEos-0.00* AbsBaso-0.00*
___ 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:20PM PLT SMR-NORMAL PLT COUNT-185
___ 01:20PM ___ PTT-32.3 ___
==================
CBC TREND
==================
___ 01:20PM BLOOD WBC-12.6* RBC-5.27 Hgb-15.4 Hct-47.7
MCV-91 MCH-29.2 MCHC-32.3 RDW-13.2 RDWSD-43.7 Plt ___
___ 01:20PM BLOOD Neuts-87* Bands-0 Lymphs-5* Monos-8 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-10.96* AbsLymp-0.63*
AbsMono-1.01* AbsEos-0.00* AbsBaso-0.00*
___ 09:52PM BLOOD WBC-12.4* RBC-4.66 Hgb-13.8 Hct-42.1
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.4 RDWSD-44.4 Plt ___
___ 02:58AM BLOOD WBC-10.5* RBC-4.28* Hgb-12.9* Hct-39.7*
MCV-93 MCH-30.1 MCHC-32.5 RDW-13.6 RDWSD-46.0 Plt ___
___ 04:08PM BLOOD WBC-7.9 RBC-3.77* Hgb-11.1* Hct-34.9*
MCV-93 MCH-29.4 MCHC-31.8* RDW-13.7 RDWSD-47.1* Plt ___
___ 05:55AM BLOOD WBC-7.0 RBC-3.86* Hgb-11.2* Hct-35.8*
MCV-93 MCH-29.0 MCHC-31.3* RDW-13.7 RDWSD-46.8* Plt ___
___ 03:44AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.1* Hct-34.8*
MCV-93 MCH-29.5 MCHC-31.9* RDW-13.3 RDWSD-45.6 Plt ___
___ 01:41AM BLOOD WBC-4.6 RBC-4.18* Hgb-12.5* Hct-37.7*
MCV-90 MCH-29.9 MCHC-33.2 RDW-12.7 RDWSD-42.3 Plt ___
___ 02:07AM BLOOD WBC-10.6*# RBC-4.42* Hgb-13.2* Hct-38.6*
MCV-87 MCH-29.9 MCHC-34.2 RDW-12.9 RDWSD-41.1 Plt ___
___ 07:00AM BLOOD WBC-8.5 RBC-4.91 Hgb-14.5 Hct-43.0 MCV-88
MCH-29.5 MCHC-33.7 RDW-13.1 RDWSD-41.3 Plt ___
___ 07:00AM BLOOD Neuts-53.7 ___ Monos-7.8 Eos-1.2
Baso-0.7 Im ___ AbsNeut-4.58# AbsLymp-2.95 AbsMono-0.66
AbsEos-0.10 AbsBaso-0.06
___ 04:41AM BLOOD WBC-10.7* RBC-4.65 Hgb-13.7 Hct-40.3
MCV-87 MCH-29.5 MCHC-34.0 RDW-13.0 RDWSD-40.4 Plt ___
___ 04:41AM BLOOD Neuts-42 Bands-0 ___ Monos-5 Eos-2
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-4.49 AbsLymp-5.46*
AbsMono-0.54 AbsEos-0.21 AbsBaso-0.00*
___ 05:16AM BLOOD WBC-12.7* RBC-4.77 Hgb-14.1 Hct-41.8
MCV-88 MCH-29.6 MCHC-33.7 RDW-12.7 RDWSD-41.0 Plt ___
___ 05:16AM BLOOD Neuts-46 Bands-0 ___ Monos-7 Eos-3
Baso-0 ___ Myelos-1* AbsNeut-5.84 AbsLymp-5.46*
AbsMono-0.89* AbsEos-0.38 AbsBaso-0.00*
==================
INFLAMMATORY MARKER TREND
==================
___ 07:52AM BLOOD CRP-203.0*
___ 04:41AM BLOOD CRP-17.2*
___ 05:16AM BLOOD CRP-11.6*
==================
MICROBIOLOGY
==================
___ 1:30 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
GRAM POSITIVE ROD(S).
==================
CREATININE TREND
==================
___ 01:20PM BLOOD Glucose-197* UreaN-26* Creat-1.9* Na-135
K-4.6 Cl-93* HCO3-28 AnGap-19
___ 09:52PM BLOOD Glucose-163* UreaN-29* Creat-1.9* Na-134
K-4.1 Cl-98 HCO3-21* AnGap-19
___ 02:58AM BLOOD Glucose-136* UreaN-24* Creat-1.9* Na-137
K-4.4 Cl-101 HCO3-21* AnGap-19
___ 04:08PM BLOOD Glucose-128* UreaN-23* Creat-1.7* Na-138
K-4.2 Cl-106 HCO3-19* AnGap-17
___ 05:55AM BLOOD Glucose-180* UreaN-24* Creat-1.7* Na-139
K-3.8 Cl-105 HCO3-19* AnGap-19
___ 03:44AM BLOOD Glucose-196* UreaN-22* Creat-1.9* Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
___ 01:41AM BLOOD Glucose-282* UreaN-22* Creat-1.5* Na-137
K-5.6* Cl-102 HCO3-25 AnGap-16
___ 07:52AM BLOOD Glucose-230* UreaN-23* Creat-1.5* Na-139
K-5.2* Cl-103 HCO3-25 AnGap-16
___ 05:38PM BLOOD Glucose-233* UreaN-28* Creat-1.6* Na-140
K-4.5 Cl-99 HCO3-26 AnGap-20
___ 02:07AM BLOOD Glucose-219* UreaN-33* Creat-1.7* Na-139
K-4.8 Cl-98 HCO3-26 AnGap-20
___ 07:00AM BLOOD Glucose-176* UreaN-44* Creat-1.8* Na-138
K-4.1 Cl-94* HCO3-25 AnGap-23*
___ 04:41AM BLOOD Glucose-131* UreaN-46* Creat-1.9* Na-135
K-3.9 Cl-94* HCO3-28 AnGap-17
___ 05:16AM BLOOD Glucose-125* UreaN-39* Creat-1.9* Na-136
K-4.0 Cl-92* HCO3-25 AnGap-23*
==================
CYTOGENETICS
==================
FISH: NEGATIVE for IGH/CCND1 (___): No evidence of
mononuclear interphase peripheral blood cells with the IGH/CCND1
gene rearrangement.
FINDINGS: A total of 200 interphase nuclei were examined with
the CCND1 and IGH dual color dual fusion probe set and
fluorescence microscopy. 196 cells (98%) had 2 red signals and 2
green signals. 0 cells (0%) had ___ yellow (red-green fusion)
signals, 1 red signal and 1 green signal. Normal cut-off values
for this probe set include: 86% for a normal 2 red and 2 green
probe signal pattern and 1.5% for a ___ yellow (red-green fusion),
1 red and 1 green signal pattern.
nuc ish(CCND1,IGH)x2[200]
FISH: NEGATIVE CLL PANEL: No evidence of mononuclear interphase
peripheral blood cells with the commonly observed cytogenetic
abnormalities of prognostic significance in chronic lymphocytic
leukemia. These include: deletions of the ATM gene and the TP53
gene, deletion 13q14, and trisomy 12.
FINDINGS: A total of 200 mononuclear interphase nuclei were
examined with the CEP12, D13S319 and LAMP tri-color
probe set and fluorescence microscopy. 198 cells (99%) had 2
green signals, 2 red signals and 2 aqua signals. 2 cells (1%)
had 2 green signals, 1 red signal, and 2 aqua signals. Normal
cut-off values for this probe set include: 80% for a normal 2
green 2 red and 2 aqua probe signal pattern and 8% for a 2
green, 1 red and 2 aqua pattern.
nuc ish(CEP12,D13S319,LAMP)x2[200]
==================
IMAGING:
==================
___ CXR (AP) FINDINGS:
The endotracheal tube tip projects over the thoracic trachea,
approximately 4.8 cm from the carina. Enteric tube terminates
in the proximal stomach. Suggest advancement so that it is well
within the stomach. The lung volumes are slightly low,
accentuating the heart size and the interstitial markings.
However, no focal consolidation is seen. There is no
appreciable pneumothorax or pleural effusion.
___ CT NECK FINDINGS:
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and
no areas of
focal mass effect. In the right side of the floor of the mouth
in the
sublingual space, there is a hypodensity measuring up to 1.8 x
0.7 cm with
subtly hyperemic wall, although wall is not well defined.
There is enlargement of the tongue. The right submandibular
gland is mildly edematous with adjacent edema and slight
hyperenhancement.
Multiple lymph nodes are prominent, measuring up to 8 mm in
cervical level 1A. Multiple mildly prominent lymph nodes are
seen within the parotid gland, more numerous than the left.
Opacification of the oro/nasopharynx is likely due to secretions
status post intubation. Small amount of debris is seen within
the trachea. An enteric tube is seen within the esophagus.
There is no retropharyngeal edema.
There is mild soft tissue stranding and edema tracking in the
bilateral neck, right neck more so than the left, deep to the
platysmus muscle (2:62) involving the jugulodigastric regions
and extending inferior with soft tissue edema of the right
subcutaneous tissue extending to the base of neck. The thyroid
gland appears normal. The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no
concerning pulmonary nodules. There are no osseous lesions
concerning for malignancy or infection. The main pulmonary
artery is dilated, measuring up to 3.2 cm, suggestive pulmonary
arterial hypertension. There is periapical lucency in the
mandible, consist with history of recent dental procedure.
IMPRESSION:
1. Hypodensity with subtle thin rim enhancement in the
sublingual space
without defined wall, concerning for evolving abscess/phlegmon;
a odontogenic source is not excluded.
2. Enlargement of the tongue.
3. Soft tissue edema deep to the platysma muscle bilaterally,
right greater than left, extending to the base of neck. No
retropharyngeal edema seen.
4. Periapical lucency in the mandible, consistent with history
of recent
dental procedure.
___ CT CHEST FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: A right PICC is seen
with its tip terminating in the lower SVC. There has been
interval extubation. An
esophageal enteric catheter traverses below the GE junction with
its tip below the field-of-view. Visualized thyroid appears
unremarkable. There is no axillary lymphadenopathy.
UPPER ABDOMEN: Please refer to the report from the concurrent CT
scan of the abdomen and pelvis for abdominopelvic findings.
MEDIASTINUM: No lymphadenopathy. Mild density likely represents
residual
thymic tissue.
HILA: Calcified left hilar lymph nodes reflect prior
granulomatous disease
exposure. No bulky hilar lymphadenopathy is seen, however.
HEART and PERICARDIUM: Mild coronary artery calcific
atherosclerosis.
Punctate aortic valve calcification is seen. Heart size is
within expected limits. There is no pericardial effusion.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: Scattered 2 mm nodules are seen in the right
upper lobe:
series 302, image 67, left upper lobe (series 302, image 85),
subpleural left lower lobe (series 302, image 112), left lower
lobe subpleural calcified granuloma (series 22, image 123), and
right lower lobe (series 3, image 2 image 144).
2. AIRWAYS: Clear
3. VESSELS: Cannot be assessed on noncontrast study.
CHEST CAGE: No suspicious lytic or blastic lesions.
IMPRESSION:
Multiple 2 mm lung nodules without definite evidence of
intrathoracic
malignancy. As per ___ recommendations, if the
patient is low risk, then no routine follow-up is necessary. If
the patient is high risk, an optional CT at 12 months is
recommended.
___ CT ABDOMEN FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced scan. There is no evidence of intrahepatic or
extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas 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 top-normal in size measuring 12.8 cm. It
demonstrates homogeneous attenuation.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The right kidney is larger compared to the left. There
is some
parenchymal thinning of the left kidney, nonspecific and may be
related to
prior insult. Scattered hypodensities are seen in the left
kidney measuring up to 1.1 cm in the lower pole. These are not
well characterized given the absence IV contrast. There is
nonspecific perinephric stranding around the left kidney. There
is no stones or hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. An enteric tube
is noted
within the gastric body. Small bowel loops demonstrate normal
caliber and
wall thickness throughout. The colon and rectum are within
normal limits. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is somewhat enlarged measuring
5.0 x 3.7 cm.
LYMPH NODES: There are scattered prominent and mildly enlarged
periportal
lymph nodes including the largest which measures 2.1 x 1.6 cm
(2:62). There are also scattered prominent retroperitoneal
lymph nodes measuring up to 6 mm in the left para-aortic station
(2:71). There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Limited assessment in the absence of IV contrast.
2. Mildly enlarged periportal lymph nodes measuring up to 2.1
cm. Scattered prominent retroperitoneal lymph nodes measuring
up to 6 mm but do not fit CT size criteria for pathologic
enlargement.
3. Borderline enlarged spleen measuring 12.8 cm.
4. Cortical thinning involving the left kidney with scattered
hypodensities which are not fully characterized on the current
study. Renal ultrasound is recommended for further evaluation.
RECOMMENDATION(S): Renal ultrasound to evaluate left renal
lesions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 100 mg PO DAILY
2. Allopurinol 50 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO BID
5. MetFORMIN (Glucophage) 200 mg PO QHS
6. Atorvastatin 20 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. glimepiride 1 mg oral DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*28 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % wash mouth with 15 mL twice a
day Refills:*0
3. Hydrochlorothiazide 50 mg PO DAILY
RX *hydrochlorothiazide 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Allopurinol 50 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Fish Oil (Omega 3) 1000 mg PO BID
8. glimepiride 1 mg oral DAILY
9. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Ludwig's Angina
SECONDARY:
Hematologic malignancy (CLL/SLL vs. Mantle Cell lymphoma)
Hypertension
T2DM
CKD
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: History: ___ with facial swelling, concern for ludwigs// air?
abscess?
TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 37.6 cm; CTDIvol = 11.5 mGy (Body) DLP = 432.0
mGy-cm.
Total DLP (Body) = 432 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect. In the right side of the floor of the mouth in the
sublingual space, there is a hypodensity measuring up to 1.8 x 0.7 cm with
subtly hyperemic wall, although wall is not well defined.
There is enlargement of the tongue. The right submandibular gland is mildly
edematous with adjacent edema and slight hyperenhancement.
Multiple lymph nodes are prominent, measuring up to 8 mm in cervical level 1A.
Multiple mildly prominent lymph nodes are seen within the parotid gland, more
numerous than the left.
Opacification of the oro/nasopharynx is likely due to secretions status post
intubation. Small amount of debris is seen within the trachea. An enteric
tube is seen within the esophagus.
There is no retropharyngeal edema.
There is mild soft tissue stranding and edema tracking in the bilateral neck,
right neck more so than the left, deep to the platysmus muscle (2:62)
involving the jugulodigastric regions and extending inferior with soft tissue
edema of the right subcutaneous tissue extending to the base of neck. The
thyroid gland appears normal. The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions concerning for malignancy or
infection. The main pulmonary artery is dilated, measuring up to 3.2 cm,
suggestive pulmonary arterial hypertension. There is periapical lucency in
the mandible, consist with history of recent dental procedure.
IMPRESSION:
1. Hypodensity with subtle thin rim enhancement in the sublingual space
without defined wall, concerning for evolving abscess/phlegmon; a odontogenic
source is not excluded.
2. Enlargement of the tongue.
3. Soft tissue edema deep to the platysma muscle bilaterally, right greater
than left, extending to the base of neck. No retropharyngeal edema seen.
4. Periapical lucency in the mandible, consistent with history of recent
dental procedure.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. in person on ___ at 4:17 pm, 10 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ett// ett
TECHNIQUE: Frontal chest radiograph
COMPARISON: None.
FINDINGS:
The endotracheal tube tip projects over the thoracic trachea, approximately
4.8 cm from the carina. Enteric tube terminates in the proximal stomach.
Suggest advancement so that it is well within the stomach. The lung volumes
are slightly low, accentuating the heart size and the interstitial markings.
However, no focal consolidation is seen. There is no appreciable pneumothorax
or pleural effusion.
IMPRESSION:
Low lung volumes. No pneumothorax or pleural effusion.
Endotracheal tube terminates 4.8 cm above the carina.
Enteric tube terminates in the proximal stomach, suggest advancement so that
it is well within the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Ludwig's angina, intubated for airway
protection, s/p I+D// Eval for interval change Eval for interval change
IMPRESSION:
In comparison with the study of ___, the endotracheal and nasogastric
tubes remain in place. Cardiac silhouette remains enlarged and there are mild
atelectatic changes at the bases. No evidence of acute focal pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with laryngeal edema with intubation// interval
change interval change
IMPRESSION:
Compared to chest radiographs ___ and ___.
ET tube in standard placement. Lungs grossly clear. Heart size top-normal.
No pleural abnormality. Nasogastric drainage tube passes to the upper
stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with laryngeal edema s/p ET tube placement//
interval change interval change
IMPRESSION:
In comparison with study of ___, the tip of the endotracheal tube is
approximately 3.7 cm above the carina. Nasogastric tube remains in good
position.
Cardiac silhouette is at the upper limits of normal in size without
appreciable vascular congestion or pleural effusion. Mild basilar atelectatic
changes bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with laryngeal edema s/p dental procedure now
intubated for airway protection// interval change interval change
IMPRESSION:
ET tube tip is 8 cm above the carinal. NG tube tip is in the stomach. Heart
size and mediastinum are stable. Interval improvement in bibasal
consolidations is present. There is no appreciable pleural effusion or
pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mr. ___ is a ___ gentleman with a past medical history
of type 2 diabetes, hypertension, CKD, gout, possible CLL/SLL vs. mantle cell
lymphoma (based on recent CBC at ___'s office) s/p recent dental procedure who
presented to the ED with swelling of the sublingual and submental regions
concerning for Ludwig's angina now s/p I+D by OMFS.// Eval for ETT placements
TECHNIQUE: Frontal chest radiograph
COMPARISON: Multiple chest radiographs, most recently dated ___.
FINDINGS:
The endotracheal tube tip projects over the mid thoracic trachea,
approximately 4 cm from the carina. The enteric tube tip projects over the
left upper quadrant.
Lung volumes remain low. Ill-defined bibasilar densities are more prominent
on today's exam compared to prior. There is no significant pleural effusion
or pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
Slightly lower lung volumes exaggerate vascular plethora at the bases.
Endotracheal tube is in appropriate positioning. No pneumothorax.
Radiology Report
INDICATION: ___ year old man with suspicion for CLL, workup for CLL.
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 4.5 s, 71.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 663.3
mGy-cm.
Total DLP (Body) = 663 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas 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 top-normal in size measuring 12.8 cm. It demonstrates
homogeneous attenuation.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The right kidney is larger compared to the left. There is some
parenchymal thinning of the left kidney, nonspecific and may be related to
prior insult. Scattered hypodensities are seen in the left kidney measuring
up to 1.1 cm in the lower pole. These are not well characterized given the
absence IV contrast. There is nonspecific perinephric stranding around the
left kidney. There is no stones or hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. An enteric tube is noted
within the gastric body. Small bowel loops demonstrate normal caliber and
wall thickness throughout. The colon and rectum are within normal limits.
The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is somewhat enlarged measuring 5.0 x 3.7 cm.
LYMPH NODES: There are scattered prominent and mildly enlarged periportal
lymph nodes including the largest which measures 2.1 x 1.6 cm (2:62). There
are also scattered prominent retroperitoneal lymph nodes measuring up to 6 mm
in the left para-aortic station (2:71). There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Limited assessment in the absence of IV contrast.
2. Mildly enlarged periportal lymph nodes measuring up to 2.1 cm. Scattered
prominent retroperitoneal lymph nodes measuring up to 6 mm but do not fit CT
size criteria for pathologic enlargement.
3. Borderline enlarged spleen measuring 12.8 cm.
4. Cortical thinning involving the left kidney with scattered hypodensities
which are not fully characterized on the current study. Renal ultrasound is
recommended for further evaluation.
RECOMMENDATION(S): Renal ultrasound to evaluate left renal lesions.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC 42cm// new R PICC 42 Contact
name: ___: ___ new R PICC 42
IMPRESSION:
Comparison to ___. The patient was extubated. The patient has
received a right PICC line. The tip of the line projects over the right
atrium. To be at the cavoatrial junction, the line needs to be pulled back by
3 cm. No complications, notably no pneumothorax. Otherwise unchanged
radiograph.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Evaluation for lymphoma.
TECHNIQUE: MD CT imaging of the chest without intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 71.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 663.3
mGy-cm.
Total DLP (Body) = 663 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W/O CONTRAST)
COMPARISON: CT neck soft tissues ___.
FINDINGS:
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: A right PICC is seen with its tip
terminating in the lower SVC. There has been interval extubation. An
esophageal enteric catheter traverses below the GE junction with its tip below
the field-of-view.
Visualized thyroid appears unremarkable.
There is no axillary lymphadenopathy.
UPPER ABDOMEN: Please refer to the report from the concurrent CT scan of the
abdomen and pelvis for abdominopelvic findings.
MEDIASTINUM: No lymphadenopathy. Mild density likely represents residual
thymic tissue.
HILA: Calcified left hilar lymph nodes reflect prior granulomatous disease
exposure. No bulky hilar lymphadenopathy is seen, however.
HEART and PERICARDIUM: Mild coronary artery calcific atherosclerosis.
Punctate aortic valve calcification is seen. Heart size is within expected
limits. There is no pericardial effusion.
PLEURA: No pleural effusion.
LUNG:
1. PARENCHYMA: Scattered 2 mm nodules are seen in the right upper lobe:
series 302, image 67, left upper lobe (series 302, image 85), subpleural left
lower lobe (series 302, image 112), left lower lobe subpleural calcified
granuloma (series 22, image 123), and right lower lobe (series 3, image 2
image 144).
2. AIRWAYS: Clear
3. VESSELS: Cannot be assessed on noncontrast study.
CHEST CAGE: No suspicious lytic or blastic lesions.
IMPRESSION:
Multiple 2 mm lung nodules without definite evidence of intrathoracic
malignancy. As per ___ Society recommendations, if the patient is low
risk, then no routine follow-up is necessary. If the patient is high risk, an
optional CT at 12 months is recommended. 4
Gender: M
Race: ASIAN - KOREAN
Arrive by WALK IN
Chief complaint: Dental pain, Neck swelling
Diagnosed with Cellulitis and abscess of mouth
temperature: 99.4
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 165.0
dbp: 82.0
level of pain: 8
level of acuity: 1.0 | Mr. ___ is a ___ gentleman with a past medical history
of type 2 diabetes, hypertension, CKD, gout, possible CLL/SLL
vs. mantle cell lymphoma (based on recent CBC at ___'s office)
s/p recent dental procedure who presented to the ED with
swelling of the sublingual and submental regions concerning for
Ludwig's angina admitted to MICU s/p I+D by OMFS.
# Ludwig's angina: The patient presented with acute
swelling/tenderness of the sublingual and submental regions
after recent dental procedure with CT on presentation showing
hypodensity in the sublingual space without defined wall. This
was consistent with possible phlegmonous changes and soft tissue
edema deep to the platysma muscle extending to the base of the
neck. Presentation was concerning for Ludwig's angina and
patient underwent I+D of the right submandibular, sublingual and
submental space abscess and hematoma with OMFS (Oral Maxillary
Facial Surgery) with primrose drains left in place. He received
IV vancomycin and Zosyn in the ED and was narrowed to Unasyn
prior to admission to the MICU. In the MICU, given persistent
fevers and concern for deterioration clinically, the patient was
re-broadened to Zosyn briefly. The patient's blood and tissue
cultures ultimately resulted in multi-organism growth without
isolated agent. With IVIG in addition to IVF and antibiotics, he
improved clinically and was transitioned back to Unasyn. The day
of discharge, his ___ drains were removed by OMFS. At
discharge he was switched from unasyn to augmentin with plan to
complete a 2 week course of augmentin after discharge up to and
including ___.
# Acute Obstructive Respiratory Failure: The patient developed
respiratory distress and failure in setting of his Ludwig's
angina and post-operative edema of his upper airways. He was
intubated ___ and supported with appropriate mouth
care and decompression via indwelling ___ drains while the
laryngeal edema slowly decreased. Approximately 72 hours
post-operatively, the patient was noted to have improvements in
edema such that he had a positive cuff leak around his ET tube.
He was extubated successfully and after discussion with
hematology/oncology (as below) and OMFS, the patient was treated
with one dose of methylprednisolone to prevent worsening edema
and recurrence of upper airway obstruction. On the floor he was
stable from a respiratory perspective.
# Hypotension: Post-operatively and on admission to the MICU,
the patient became hypotensive to ___. This was felt to be
hypovolemic in nature and he was given multiple units of IVF
with good response in both blood pressures and urine output.
# ?CLL/SLL vs. mantle cell lymphoma: Based on recent CBC at
___'s office showing lymphocytosis and smudge cells, there was
concern for some form of hematologic malignancy in the patient.
The main differential diagnoses include atypical chronic
lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and
mantle cell lymphoma without clear diagnosis as of yet. During
this admission, hematology/oncology was consulted, who
recommended CT torso with PO contrast (unable to obtain IV given
CKD with superimposed ___ to evaluate for any large masses and
potential biopsy target. This was unfortunately unrevealing.
Attempts were also made to avoid corticosteroid therapy for sake
of preserving utility of possible biopsy and cancer work-up.
However, the patient ultimately, as detailed below, received 1
dose of methylprednisolone ___ to assist in
decreasing airway edema. The patient was transferred to the
floor with plans to continue outpatient work-up and management
of this possible malignancy.
# Hypogammaglobulinemia: Per recommendation of Heme/Onc, the
patient was found to have low immunoglobulins, likely as a
result of his undiagnosed hematologic malignancy. He was treated
with one dose of IVIG to facilitate recovery from his ongoing
infection. He tolerated this infusion without any adverse
effects and improved with respect to his infection as well.
# ___ on CKD: the patient has baseline CKD without known
baseline (but last know of ~1.5-1.7). His Cr was mildly elevated
this admission, likely due to effective pre-renal azotemia in
setting of infection. He was supported with IVIF and medications
were renally dosed. At time of transfer from ICU to the general
medical floor, the patient's Cr had returned to about his
baseline range.
# Type 2 DM: The patient was on home oral anti-hyperglycemics,
which were held during admission in favor of sliding scale
insulin. At discharge he was restarted on his oral sulfonylurea
but metformin was held given renal insufficiency and risk of
lactic acidosis.
# Hypertension: The patient's blood pressure as above was
initially low in setting of sedation and infection. With
extubation and withdrawal of sedative medications, the patient's
blood pressures rose to 220's/110's. Given ___ on CKD, home
atenolol was avoided. He was given labetalol (both IV and
subsequently PO), briefly managed on a nitroglycerin drip,
restarted on home losartan (with improvements in renal
function), and initiated on HCTZ. With this regimen, his blood
pressure was stable around 140-150's systolic at time of
transfer to the general medical floor. Labetalol was
downtitrated prior to discharge due to orthostasis and was
changed to metoprolol at discharge.
# Hyperlipidemia: The patient's atorvastatin and fish oil were
initially held but subsequently restarted once able to take PO
medications.
TRANSITIONAL ISSUES:
====================
[] Antibiotic course: Continue PO Augmentin on discharge up to
and including ___.
[] Hematological Malignancy: Patient was noted at outpatient
appt prior to admission to have a monoclonal B cell (CD10-,
CD5+, CD23-) population on peripheral blood FACS suggestive of a
B-cell lambda-restricted lymphoproliferative disorder, possibly
CLL/SLL or mantle cell lymphoma. FISH was negative for 11;14
translocation and non-contrast chest CT without a clear primary
mass, but full workup was deferred to outpatient follow-up given
infection, prednisone, and IVIG (for hypogammaglobulinemia)
during admission and no acute inpatient oncologic issues. An
appointment with heme/onc was pending at time of discharge.
[] Medication changes: For his hypertension, STOPPED atenolol,
started metoprolol succinate 25 mg daily. Started
hydrochlorothiazide. Should have close monitoring of BPs,
titration as needed, and repeat chem panel at follow up
appointment.
[ ] Pt was orthostatic on ___, after which labetalol was
stopped. Repeat orthostatics at PCP follow up.
[ ] Aspirin held at discharge, consider restarting at follow up
appointment.
[] Type 2 Diabetes Mellitus: Stopped metformin due to renal
insufficiency. Had some elevated blood sugars in the hospital
likely related to steroid use; closely monitor blood sugars and
consider uptitrating oral sulfonylurea. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP
___: open cholecystectomy
History of Present Illness:
___ yo F with NIDDM, CAD s/p CABG, HTN, porcine AVR and obesity
who presents to the ED from ___ where she was found to
have a 14 mm CBD dilatation on CT scan.
.
Patient reports four days of constant RUQ abdominal pain that
radiates throughout the abdomen. Pain worse with eating. Also
with decreased appetite and increased fatigue. Reports
subjective fevers and chills. No nausea, but two episodes of
vomiting (non-bloody), no diarrhea. Denies any change in color
of skin. No weight loss.
.
Went to ___ where labs were significant for elevated
tbili 1.13 and normal LFTs. CT a/p showed cholelithiasis and 14
mm CBD dilation with no obvious cause for dilatation. Patient
was given 3gm of Unasyn and transferred to ___ for ERCP
evaluation.
.
ED: 100.4 68 104/48 16 97%; tylenol 1gm. Surgery consulted and
agrees with plan for ERCP. ERCP fellow notified.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
Aortic Stenosis s/p porcine AVR in ___
Coronary Artery Disease s/p CABG in ___
Hypertension
Type 2 Diabetes Mellitus
Obesity
Depression
s/p Right cataract surgery
s/p Tonsillectomy
s/p Partial hysterectomy for ruptured ovarian cyst
s/p incisional hernia repair
Social History:
___
Family History:
No known hepatobiliary disease
Physical Exam:
VS: 96.8 142/60 72P 16 100%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, ___ systolic murmur at RUSB, no peripheral edema,
2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: obese, soft, + ruq ttp, no distension, no rebound/guarding,
+bs, neg murphysMsk: ___ strength throughout, no joint swelling,
no cyanosis or clubbing
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes, mid thoracic scar
Psych: appropriate, pleasant
Heme: no cervical ___
___ examination upon discharge:
Vital signs: t=98.7, hr-69, rr=16, bp=118/68, oxygen sat=99%
General: NAD, sitting in chair
CV: Ns1, s2, -s3, -s4, +Grade ___ systolic murmur, ___ ICS,
RSB, LSB, ___ ICS, LSB
LUNGS: clear'
ABDOMEN: soft, non-tender, sero-sanguinous oozing from right
abdominal drain site, mild erythema around staples
EXT: + dp bil., no pedal edema bil.
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 04:37AM BLOOD WBC-7.2 RBC-2.65* Hgb-7.8* Hct-22.8*
MCV-86 MCH-29.3 MCHC-34.2 RDW-13.7 Plt ___
___ 05:06AM BLOOD WBC-9.2 RBC-2.59* Hgb-7.7* Hct-22.3*
MCV-86 MCH-29.8 MCHC-34.6 RDW-13.7 Plt ___
___ 10:30AM BLOOD WBC-11.4* RBC-2.82* Hgb-8.3* Hct-24.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-13.5 Plt ___
___ 01:40AM BLOOD WBC-12.0*# RBC-3.82* Hgb-11.4* Hct-33.1*
MCV-87 MCH-29.9 MCHC-34.5 RDW-13.3 Plt ___
___ 01:40AM BLOOD Neuts-82.3* Lymphs-10.6* Monos-6.4
Eos-0.4 Baso-0.4
___ 04:37AM BLOOD Plt ___
___ 01:40AM BLOOD ___ PTT-26.0 ___
___ 05:06AM BLOOD Glucose-136* UreaN-11 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-26 AnGap-11
___ 10:30AM BLOOD Glucose-238* UreaN-11 Creat-0.9 Na-135
K-4.4 Cl-104 HCO3-24 AnGap-11
___ 04:30AM BLOOD Glucose-166* UreaN-10 Creat-1.1 Na-141
K-4.7 Cl-107 HCO3-25 AnGap-14
___ 06:00PM BLOOD Glucose-159* UreaN-10 Creat-1.0 Na-137
K-4.1 Cl-105 HCO3-24 AnGap-12
___ 01:10AM BLOOD CK(CPK)-187
___ 05:18PM BLOOD CK(CPK)-227*
___ 01:40AM BLOOD ALT-15 AST-15 LD(LDH)-169 AlkPhos-56
Amylase-27 TotBili-1.3
___ 10:40AM BLOOD CK-MB-4 cTropnT-0.03*
___ 05:06AM BLOOD CK-MB-4 cTropnT-0.04*
___ 01:10AM BLOOD CK-MB-5 cTropnT-0.04*
___ 05:18PM BLOOD CK-MB-6 cTropnT-0.03*
___ 05:06AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8
___ 10:30AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.9
___: chest x-ray:
FINDINGS: In comparison with study of ___, there is little
overall
change. Evidence of previous CABG procedure with intact midline
sternal
wires. Moderate cardiomegaly without vascular congestion or
acute focal
pneumonia
___: ERCP:
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. Post
sphincterotomy, pus was noted to spontaneously drain out of the
major papilla.
Five pigment stones were extracted successfully using a balloon.
Some amount of sludge and pus were also extracted successfully.
___: chest x-ray:
There are low lung volumes. There is mild cardiomegaly. There is
mild
vascular congestion. There are bibasilar atelectasis. There is a
plate-like atelectasis in the left mid lung. There is no
pneumothorax or pleural
effusion. Sternal wires are aligned. Patient is status post
CABG.
Medications on Admission:
FLUOXETINE - 40 mg Capsule - 1 Capsule(s) by mouth once a day
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
PRAVASTATIN - 20 mg Tablet - one Tablet(s) by mouth daily
SPIRONOLACTONE - 12.5 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day
CETIRIZINE - 10 mg Tablet - one Tablet(s) by mouth daily
FLONASE
COENZQ 10 DAILY
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day: hold for loose stool.
12. Januvia 50 mg Tablet Sig: One (1) Tablet PO bedtime ().
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Cholelithiasis
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Preoperative.
FINDINGS: In comparison with study of ___, there is little overall
change. Evidence of previous CABG procedure with intact midline sternal
wires. Moderate cardiomegaly without vascular congestion or acute focal
pneumonia.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Status post cholecystectomy with rapid Afib.
There are low lung volumes. There is mild cardiomegaly. There is mild
vascular congestion. There are bibasilar atelectasis. There is a plate-like
atelectasis in the left mid lung. There is no pneumothorax or pleural
effusion. Sternal wires are aligned. Patient is status post CABG.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FOR ERCP
Diagnosed with CHOLANGITIS, ABDOMINAL PAIN RUQ
temperature: 100.4
heartrate: 68.0
resprate: 16.0
o2sat: 97.0
sbp: 104.0
dbp: 48.0
level of pain: 2
level of acuity: 2.0 | ___ year old female admitted to the acute care service with right
upper quadrant pain, fever, and an elevated bilirubin. A cat
scan done at an outside hospital showed cholilithiasis and a
dilated common bile duct. Upon admission, she was made NPO,
given intravenous fluids, and started on unasyn. She underwent
an ERCP on HD # 2 where she underwent a sphincterotmy with the
extraction of stones, sludge and pus. Her vital signs and liver
enzymes were monitored after the procedure.
On HD # 4, she was taken to the operating room where she
underwent an open cholecystectomy because of inability to gain
adequate exposure with a laparoscopic approach. She had a 1500
cc blood loss during the procedure. A ___ drain was
left in the gallbladder bed because of the extensive dissection.
She received a 24 hour course of ciprofloxacin and flagyl. She
was successfully extubated after the procedure.
Post-operatively, she required additional intravenous fluid for
a low urine output. On POD #1, she was started on sips. She
continued on intravenous analgesia for pain management and she
began ambulating with assistance. She was evaluated by physical
therapy who recommended use of a walker to help with her
balance. Her vital signs remained stable. She was gradually
advanced to a regular diet by POD2 which she was tolerating
well. On POD#3, she went into atrial fibrillation with a rapid
ventricular response. She was given intravenous diltiazem and
converted into NSR after a valsalva while moving her bowels.
Her electrolytes were closely monitored and she has not had a
recurrence of irregular heart rhythm. She was noted to have a
slight increase in her troponins on POD # 3 and 4. Her troponins
continued to be cycled and were slowly decreasing.
Her JP drain was discontinued on POD # 4. Her vital signs are
stable and she is afebrile. She is preparing for discharge
home with instructions to follow-up in the acute care clinic and
with her primary care provider.
.
Emergency contact: ___ (spouse) ___
Email sent to Dr. ___ of admission |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Removal of hardware, retrograde nail
History of Present Illness:
___ h/o HTN, osteopenia, GERD, and fall from ladder in
___ that required ORIF L femur for fracture.
Recovering as expected, but fractured through plate without new
trauma today. Patient notes she was ambulating as normal and
had
increased pain without new injury. She presented to local ER
for
evaluation and x-rays revealed fracture through plate, so she
was
sent to ___ for further evaluation and treatment. Of note,
she
has been followed by a Dr. ___ and her original
surgery
was at ___. She was recovering as expected, but
new the injury had not healed yet, but was following her weight
bearing instructions.
Past Medical History:
HTN, GERD, osteopenia (on Fosamax)
Ex fix for initial injury followed by definitive fixation.
No bleeding or clotting disorders.
No issues with anesthesia
Social History:
___
Family History:
non-contributory
Physical Exam:
AOx3
LLE: dressing C/D/I, SILT ___ n distributions, Fires
___, wwp distally
Pertinent Results:
___ 08:45AM BLOOD WBC-9.7 RBC-2.40* Hgb-7.4* Hct-22.4*
MCV-93 MCH-30.8 MCHC-33.0 RDW-13.2 RDWSD-45.1 Plt ___
___ 05:15AM BLOOD WBC-8.3 RBC-2.42* Hgb-7.3* Hct-22.4*
MCV-93 MCH-30.2 MCHC-32.6 RDW-13.1 RDWSD-44.0 Plt ___
___ 03:16PM BLOOD WBC-12.9* RBC-2.93*# Hgb-9.0*# Hct-27.3*#
MCV-93 MCH-30.7 MCHC-33.0 RDW-13.2 RDWSD-44.8 Plt ___
___ 03:20PM BLOOD WBC-10.8* RBC-4.23 Hgb-12.9 Hct-38.3
MCV-91 MCH-30.5 MCHC-33.7 RDW-13.2 RDWSD-44.0 Plt ___
___ 08:45AM BLOOD Glucose-99 UreaN-9 Creat-0.5 Na-135 K-4.0
Cl-98 HCO3-26 AnGap-15
___ 05:15AM BLOOD Glucose-110* UreaN-7 Creat-0.6 Na-137
K-3.5 Cl-100 HCO3-28 AnGap-13
___ 06:52PM BLOOD Glucose-126* UreaN-14 Creat-0.8 Na-135
K-3.9 Cl-100 HCO3-27 AnGap-12
___ 03:20PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-140
K-4.3 Cl-101 HCO3-25 AnGap-18
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 37.5 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Loratadine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*70 Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Venlafaxine 37.5 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Periprosthetic 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
INDICATION: History: ___ with femur fracture and h/o fluid overload; pain,
injury// Pre op; h/o fluid overload
TECHNIQUE: Semi supine AP portable view of the chest
COMPARISON: None.
FINDINGS:
The lungs are relatively hyperinflated which could be due to COPD. There is
mild biapical pleural thickening, right greater than left.. No focal
consolidation is seen. There is no pleural effusion or pneumothorax. The
cardiac silhouette is borderline in size. Mediastinal contours are
unremarkable. No pulmonary edema is seen.
IMPRESSION:
No evidence of fluid overload, including pulmonary edema.
Radiology Report
INDICATION: Femur fracture. ORIF.
COMPARISON: None
IMPRESSION:
Fluoroscopic images of the left femur from the operating room demonstrate
interval placement of a retrograde nail with interlocking screws. No hardware
related complications are seen. This is stabilizing an oblique fracture of
the distal femur. There are several lucencies throughout the distal femur
consistent with prior hardware screw tracts. The total intraservice
fluoroscopic time is 136.2 seconds. Please refer to the operative note for
additional details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Femur fracture, L Leg pain, Transfer
Diagnosed with Breakdown (mechanical) of int fix of left femur, init, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 97.9
heartrate: 109.0
resprate: 16.0
o2sat: 98.0
sbp: 142.0
dbp: 69.0
level of pain: 10
level of acuity: 2.0 | 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 left femur removal of hardware
and retrograde IMN, 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 home with home ___ was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the 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: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with obesity, gout, HTN, and h/o
nausea/vomiting which has been attributed to possible GERD vs
gastroparesis who presented to the ED due to left-sided
abdominal pain.
She was in her usual state of good health until 2 days ago when
she felt the suddne onset of severe left-sided abdominal pain,
colicy in nature, with no frank dysuria, frequency, or urgency.
She has no relief from the pain and states that it radiates to
her back/flank occasionally, not involving the chest. She has
not had similar pain before. No nausea, vomiting, or diarrhea
although she is not eating much due to the pain. No hematuria.
She did note that she usually has a BM daily but has not had one
for 4 days (though she is passing gas). Due to the pain, she
decided to come to the ED.
In the ED, initial vs were 10 99.8 86 170/91 18 99% RA. Exam
was not concerning. Labs (CBC, CHEM7, LFTs) were normal.
Lipase 20. UA was contaminated. She received Morphine 5mg IV
x3. CXR was without infiltrate. Underwent CT abd/pelvis which
showed an abdominal wall hernia containing loops of small bowel
with no evidence of obstruction, as well as a pelvic mass. ACS
was consulted for the hernia and felt there was no clinical
signs of obstruction, there was no sign of incarceration, and
this was an unlikely cause for her symptoms. Ob/Gyn was
consulted for the pelvic mass, and after pelvic U/S felt that
this mass warrants outpatient MRI but is not the likely cause of
her symptoms. The ED was concerned about her IV pain medication
requirement, and due to her left-sided CVA tendernedd was
concerned about possible pyelo (patient declined straight cath
to repeat UA) so decided to admit to Medicine. Transfer VS were
98.6, 92, 16, 142/75, 97 RA.
On arrival to the floor, patient reports continued pain,
colicky. She is otherwise feeling fine.
ROS
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Obesity
Gout
Diabetes mellitus (HbA1c 6.5% in ___
Hyperlipidemia
Hypertension (on multiple meds)
LVH/diastolic dysfunction on TTE ___
Anemia
Osteoarthritis
Constipation
Diverticulosis
Depression
h/o nausea/vomiting (GERD vs stress vs gastroparesis)
Social History:
___
Family History:
-mother- ___, HTN, DM II
-father-HTN, died at age ___ from liver cancer
-breast cancer in two sisters, one was in her ___ and the other
was at age ___
-brother with MI in ___
-HTN in sisters
-No h/o other cancers including uterine or colon cancer.
Physical Exam:
Admission:
VS 99, 165/83, 93, 95% RA, 149
GEN Alert, oriented, no acute distress, obese
HEENT NCAT MMM EOMI 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 obese, soft NT ND normoactive bowel sounds, no r/g
BACK Tenderness to palpation along left flank
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge:
VS 97.6-99.1, 126-180/70-87, 72-89, 97-100%
GEN Alert, oriented, no acute distress, obese
HEENT NCAT MMM EOMI 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 obese, soft NT ND normoactive bowel sounds, no r/g
BACK Tenderness to palpation along left flank and midline/ spine
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Negative straight leg test
Pertinent Results:
___ 11:15PM BLOOD WBC-9.9 RBC-4.54 Hgb-12.5 Hct-39.8 MCV-88
MCH-27.4 MCHC-31.3 RDW-14.3 Plt ___
___ 06:45AM BLOOD WBC-9.9 RBC-4.21 Hgb-11.7* Hct-36.4
MCV-86 MCH-27.8 MCHC-32.2 RDW-14.2 Plt ___
___ 11:15PM BLOOD Neuts-74.6* Lymphs-17.7* Monos-6.1
Eos-1.2 Baso-0.5
___ 11:15PM BLOOD Glucose-161* UreaN-17 Creat-1.0 Na-140
K-4.2 Cl-102 HCO3-28 AnGap-14
___ 06:45AM BLOOD Glucose-122* UreaN-16 Creat-0.9 Na-141
K-4.1 Cl-99 HCO3-30 AnGap-16
___ 11:15PM BLOOD ALT-16 AST-15 AlkPhos-58 TotBili-0.6
___ 11:15PM BLOOD Lipase-20
___ 06:45AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.0 UricAcd-8.0*
___ 06:45AM BLOOD CEA-1.6 AFP-1.4 CA125-10
___ 11:24PM BLOOD Lactate-1.1
___ 06:45AM BLOOD CA ___ -PND
___ 05:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:45PM URINE RBC-0 WBC-10* Bacteri-MOD Yeast-NONE
Epi-0
___ 12:45PM URINE Hours-RANDOM Creat-167 Calcium-8.5 Uric
Ac-82.4
___ 2:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Urine culture pending x2
Blood culture pending x1
Imaging:
CHEST (PA & LAT) Study Date of ___ 12:55 AM
FINDINGS: The lungs are clear with no evidence of
consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. A small hiatal hernia is noted. No acute
fractures are identified. No free air is noted under the
hemidiaphragms.
IMPRESSION: No acute cardiopulmonary process.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1:49 AM
CT OF THE ABDOMEN WITH IV CONTRAST:
The visualized lung bases demonstrate mild bibasilar
atelectasis. The liver, gallbladder, spleen, bilateral adrenal
glands, and bilateral kidneys appear normal. The pancreas
appears atrophic, but otherwise unremarkable. There is a small
hiatal hernia. There is also a mid abdominal hernia containing
loops of small bowel; however, there is no evidence of infection
and the visualized loops of small and large bowel are within
normal limits. No free fluid or free air in the abdomen. No
mesenteric or retroperitoneal lymphadenopathy. The abdominal
aorta is normal in caliber and contour.
CT OF THE PELVIS WITH IV CONTRAST:
The uterus appears heterogeneous, enlarged, with multiple
hypodense areas as well as clacifications. Additionally, there
is an adjacent fat containing lesion measuring 5.3 cm (AP) x 6.4
cm (transverse) x 6.6 cm (craniocaudad) (2:56, 300B:24).
Otherwise, the rectum and sigmoid colon are within normal
limits. 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. The uterus appears enlarged and heterogeneous with multiple
hypodense
areas as well as calcification. As a result, a dedicated pelvic
MRI is
recommended for further characterization.
2. Adjacent to the uterus is a fat-containing mass measuring
6.4 x 5.3 x 6.6 cm. This mass is most likely representative of
an ovarian dermoid. However, this lesion can also be further
characterized on MRI.
2. Mid abdominal wall hernia containing loops of small bowel
with no evidence of obstruction. No acute abdominal or pelvic
processes are otherwise noted.
PELVIS U.S., TRANSVAGINAL Study Date of ___ 9:30 AM
FINDINGS: Transabdominal and transvaginal ultrasound
examinations were
performed, the latter to further assess the endometrium and
adnexa. The
uterus is enlarged, measuring 14.7 x 7.1 x 9.0 cm, and contains
multiple
masses compatible with fibroids, the largest of which measures
4.9 x 4.1 x 4.5 cm. The endometrium is distorted by fibroids
and is where clearly seen is thickened to 7 mm. Neither ovary
is well seen. In the right adnexal region, a 6.4 x 6.5 x 7.2 cm
hyperechoic mass with posterior acoustic shadowing is seen,
compatible with an ovarian dermoid. A tubular structure
measuring up to 7 mm in diameter in the right adnexal region is
compatible with hydrosalpinx.
IMPRESSION:
1. Right ovarian dermoid, measuring up to 7.2 cm.
2. Possible mild right hydrosalpinx.
3. Thickened endometrium to 7 mm. Biopsy should be considered
for further evaluation, if not recently performed.
4. Fibroid uterus.
Medications on Admission:
Simvastatin 10 mg QHS
docusate sodium 100 mg BID PRN
hydrochlorothiazide 25 mg daily
lisinopril 10 mg daily
naproxen 375 mg daily PRN
Discharge Medications:
1. Simvastatin 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Hold for SBP<100
5. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg daily Disp #*30 Tablet Refills:*0
6. Naproxen 375 mg PO DAILY:PRN pain
7. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
Hold for sedation/ RR<10
RX *Oxecta 5 mg every 6 hours as needed for pain Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: back pain, pelvic mass, umbilical hernia
Secondary: Hypertension, gout, hyperlipidemia, diabetes,
osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left upper abdominal pain.
COMPARISON: CT abdomen and pelvis from the same day.
FINDINGS: The lungs are clear with no evidence of consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal. A small hiatal
hernia is noted. No acute fractures are identified. No free air is noted under
the hemidiaphragms.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Left-sided abdominal pain.
COMPARISON: Abdominal ultrasound from ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the base of the
lungs to the pubic symphysis after the administration of intravenous contrast.
Multiplanar reformatted images were prepared and reviewed.
DLP: 870 mGy-cm.
FINDINGS:
CT OF THE ABDOMEN WITH IV CONTRAST:
The visualized lung bases demonstrate mild bibasilar atelectasis. The liver,
gallbladder, spleen, bilateral adrenal glands, and bilateral kidneys appear
normal. The pancreas appears atrophic, but otherwise unremarkable. There is
a small hiatal hernia. There is also a mid abdominal hernia containing loops
of small bowel; however, there is no evidence of infection and the visualized
loops of small and large bowel are within normal limits. No free fluid or
free air in the abdomen. No mesenteric or retroperitoneal lymphadenopathy.
The abdominal aorta is normal in caliber and contour.
CT OF THE PELVIS WITH IV CONTRAST:
The uterus appears heterogeneous, enlarged, with multiple hypodense areas as
well as clacifications. Additionally, there is an adjacent fat containing
lesion measuring 5.3 cm (AP) x 6.4 cm (transverse) x 6.6 cm (craniocaudad)
(2:56, 300B:24). Otherwise, the rectum and sigmoid colon are within normal
limits. 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. The uterus appears enlarged and heterogeneous with multiple hypodense
areas as well as calcification. As a result, a dedicated pelvic MRI is
recommended for further characterization.
2. Adjacent to the uterus is a fat-containing mass measuring 6.4 x 5.3 x 6.6
cm. This mass is most likely representative of an ovarian dermoid. However,
this lesion can also be further characterized on MRI.
2. Mid abdominal wall hernia containing loops of small bowel with no evidence
of obstruction. No acute abdominal or pelvic processes are otherwise noted.
Radiology Report
INDICATION: ___ postmenopausal female with left lower quadrant and
suprapubic pain. Abnormal pelvic mass on CT. Evaluate for uterine mass,
abnormal flow, or ovarian torsion.
COMPARISONS: CT abdomen and pelvis ___.
FINDINGS: Transabdominal and transvaginal ultrasound examinations were
performed, the latter to further assess the endometrium and adnexa. The
uterus is enlarged, measuring 14.7 x 7.1 x 9.0 cm, and contains multiple
masses compatible with fibroids, the largest of which measures 4.9 x 4.1 x 4.5
cm. The endometrium is distorted by fibroids and is where clearly seen is
thickened to 7 mm. Neither ovary is well seen. In the right adnexal region,
a 6.4 x 6.5 x 7.2 cm hyperechoic mass with posterior acoustic shadowing is
seen, compatible with an ovarian dermoid. A tubular structure measuring up to
7 mm in diameter in the right adnexal region is compatible with hydrosalpinx.
IMPRESSION:
1. Right ovarian dermoid, measuring up to 7.2 cm.
2. Possible mild right hydrosalpinx.
3. Thickened endometrium to 7 mm. Biopsy should be considered for further
evaluation, if not recently performed.
4. Fibroid uterus.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LLQ PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED, ABDOM/PELV SWELL/MASS UNSP SITE
temperature: 99.8
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 170.0
dbp: 91.0
level of pain: 10
level of acuity: 3.0 | ___ lady with obesity, gout, HTN, and h/o nausea/vomiting
which has been attributed to possible GERD vs gastroparesis who
presented to the ED due to left-sided abdominal pain/ back pain.
# Left-sided colicky abdominal/ back pain: By history,
concerning for nephrolithiasis, given sudden onset, squeezing
nature, absence of systemic symptoms of fevers/ chills, no
dysuria, frequency, urgency or trauma. 3 UAs were sent and one
was consistent with a UTI with positive leuks and nitrites (CT
without evidence of renal stranding/ pyelo) and final UA was
normal, with no treatment. UA pH 5.5, less likely infectious
nephrolithiasis. Also possible is musculoskeletal back pain
given exacerbation with walking/ movement. Urine calcium 8.5,
uric acid 82.4. We filtered urine looking for stone but found
nothing. Pain control with PO oxycodone and Tylenol. She was
seen by ___ who recommended rehab, which patient refused, but did
agree with outpatient physical therapy. Patient discharged with
oxycodone x20 pills and senna/ docusate.
- Outpatient MRI for ? back pain given pelvic mass.
- f/u final urine cultures to determine if UTI present
# Pelvic mass/ right ovarian dermoid: measuring up to 7.2cm by
US: concern for malignancy, although no acute intervention while
in house. Patient evaluated by ob/gyn in the ED and had
non-obstetric ultrasound and was set up with outpatient follow
up. Initial tumor markers were within normal limits, although
___ pending at time of discharge.
- Thickened endometrium to 7 mm. Biopsy should be considered
for further
evaluation, if not recently performed.
# Umbilical hernia: Not incarcerated by CT scan and evaluated
by surgery in the ED. Determined that patient could be seen as
an outpatient in clinic for follow up given risk of developing
enterocutaneous fistula.
# Hypertension: Patient hypertensive in context of missing
medications in ED. Has been hypertensive in clinic visits as
well. Given initial concern of gout, patient started on
amlodipine 5mg in place of HCTZ 25 and continued on Lisinopril
10mg qd. She was started back on HCTZ at discharge.
# HL: TC 241, HDL63, LDL 161 from ___. We continued Simva 10mg
qd
# Gout: Not active, although mildly elevated uric acid. We did
not start allopurinol and continued HCTZ as above.
# Transitional:
- Outpatient MRI for ? back pain given pelvic mass.
- Outpatient gyn follow up for ovarian dermoid/ fibroid uterus,
thickened endometrium and follow up tumor markers.
- Outpatient surgery follow up for umbilical hernia
- Consider transition away from HCTZ.
- Urine cultures x2 and blood culture x1 pending |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath (___)
History of Present Illness:
Mr. ___ is a ___ M w/ DM, AFib and HTN who presented to ED w/
one day of epigastric pain, EKG changes, and a troponin leak
most consistent with Acute coronary syndrome.
In ED, patient reported epigastric ___ pressure while at rest
which was non-radiating. Pain started while sitting, then lasted
until he fell ___ hours). Patient noted similar pain the
morning of admission after taking daily medications. He took ASA
325 mg at home with complete relief of symptoms. Denied pain on
exertion, SOB, N/V, or diaphoresis.
ED Course:
Initial Vitals: pain ___ HR 74 140/82 15 94%. Trop:
0.27, INR of 1.0 and hemeoccult neg, will start heparin. EKG:
Sinus Rhythm at 75 ant/septal and lateral ST-T changes, ST
elevation in III, and + TWI. Cards consult: dx NSTEMI vs missed
STEMI, admit, cath in AM. Heparin gtt initiated; guaiac neg
At time of transfer to floor vitals were: 98.4 HR 57 122/67 21
95% RA
On arrival to floor, patient denies any chest pain, abdominal
pain, or dyspnea. Overall, feels well.
ROS: + diarrhea x1 month with some normal BM's usually after
takes meds; Otherwise full 10 pt review of systems negative
except for above. Of note, no denies any abdominal pain,
dyspnea, fever, nausea or vomiting.
Past Medical History:
- Diabetes mellitus type II: oral agents & insulin
- Atrial Fibrillation
- Hypertension
Social History:
___
Family History:
Father MI in late ___, Mother DM
Physical ___:
Admission Physical Exam:
VS: 98.0 122/80 HR 70 sat 98% on RA; weight 92 kg
Gen: NAD
HEENT: clear OP
CV: NR, RR, no murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND
GU: no Foley
Ext: no edema
Skin: no lesions noted
Neuro: no gross deficits, A&Ox3
Psych: appropriate
.
Discharge Physical Exam:
VS: T: 98.0 BP: 140/76(120/79-154/92) HR: 78(58-82) O2 sat:
95% on RA; Wt. 90.9 kg (92 kg admission)
Gen: alert and awake, no acute distress
HEENT: anicteric sclera, oropharynx clear
CV: regular rate and rhythm, with no murmur/gallops/rubs
Pulm: clear to ascultation bilaterally, no wheezes or crackles
Abd: soft, non-tender, non-distended, BS present
GU: no Foley
Ext: 2+ dp pulses bilaterally, no clubbing, cyanosis, edema
Skin: warm, dry, no rashes
Neuro: CNII-XII grossly intact and symmetric, no gross motor
deficits
Pertinent Results:
Admission Labs:
___ 03:23PM ___ PTT-30.3 ___
___ 03:23PM PLT COUNT-260
___ 03:23PM NEUTS-77.3* LYMPHS-16.7* MONOS-4.7 EOS-0.3
BASOS-1.0
___ 03:23PM WBC-9.5 RBC-4.66 HGB-15.0 HCT-43.6 MCV-94
MCH-32.2* MCHC-34.4 RDW-12.9
___ 03:23PM cTropnT-0.27*
___ 03:23PM estGFR-Using this
___ 03:23PM GLUCOSE-286* UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
___ 09:45PM cTropnT-1.77*
___:37PM PTT-52.7*
.
Interval Labs:
___ 05:30AM BLOOD WBC-9.3 RBC-4.37* Hgb-14.3 Hct-40.4
MCV-92 MCH-32.7* MCHC-35.4* RDW-12.1 Plt ___
___ 05:30AM BLOOD ___ PTT-49.1* ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-244* UreaN-13 Creat-0.6 Na-138
K-3.9 Cl-102 HCO3-25 AnGap-15
___ 05:30AM BLOOD cTropnT-1.55*
___ 05:30AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9
.
Discharge Labs:
___ 05:40AM BLOOD WBC-8.2 RBC-4.38* Hgb-14.5 Hct-40.3
MCV-92 MCH-33.1* MCHC-36.0* RDW-12.2 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___ PTT-59.9* ___
___ 05:40AM BLOOD Glucose-220* UreaN-13 Creat-0.7 Na-135
K-4.2 Cl-100 HCO3-23 AnGap-16
___ 05:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
.
Microbiology: None.
.
Pathology: None.
.
Imaging/Studies:
# CXR (___): IMPRESSION: No evidence of an acute
cardiopulmonary process.
# ECG (___): Sinus rhythm. ST segment elevation in leads III
and possibly lead aVF. T wave inversions in leads V4-V6. ST
segment depressions in leads I and V6 consistent with acute
ischemia or an infarction. No previous tracing available for
comparison.
# ECG (___): Sinus rhythm. Similar to tracing #1.
# ECG (___): Sinus rhythm with partial resolution of the
ST-T wave abnormalities in the anterolateral wall.
# ECG (___): Sinus rhythm. Similar to tracing #3.
# Cardiac Cath (___):
Findings
ESTIMATED blood loss: < 50 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: Mild diffuse
LAD: Proximal diffuse 30%; Mid 40%; Calcified;
LCX: Diffuse disease with mid 40%;
RCA: Heavily calcified; Severe diffuse ectasia and tortuosity;
Lesion severity difficult to assess due to tortuosity; Visual
estimate is 60-70% proximal, 70% mid and 60-70% distal.
Assessment & Recommendations
1. Severe diffuse single vessel CAD involving the RCA. Actual
flow limiting lesions uncertain given reasonable lumen diameter.
The vessel is high risk target for PCI. Favor medical therapy to
include dual anti-platelet therapy, high dose statin, and
probable beta blocker. If symptoms or high risk ETT on medical
therapy can consider high-risk PCI.
# Trans-thoracic Echocardiogram (___):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to apical hypokinesis with focal apical
dyskinesis. The inferior and posterior walls (suboptimally
visualized) may also be hypokinetic. Right ventricular chamber
size and free wall motion are normal. There are focal
calcifications in the aortic arch. 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. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 120 mg PO Q24H
2. MetFORMIN XR (Glucophage XR) 500 mg PO BID
3. Lisinopril 15 mg PO HS
4. Simvastatin Dose is Unknown PO DAILY
5. GlipiZIDE XL 5 mg PO BID
6. levemir 18 Units Bedtime
Discharge Medications:
1. GlipiZIDE XL 5 mg PO BID
2. MetFORMIN XR (Glucophage XR) 500 mg PO BID
3. Lisinopril 15 mg PO HS
4. Atorvastatin 80 mg PO HS
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. levemir 18 Units Bedtime
7. Verapamil SR 120 mg PO Q24H
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet, chewable(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain. Rule out acute process.
COMPARISON: None available.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. There is
mild calcification of the aortic knob. Linear opacity seen in the left upper
lung field, right lung base and lingula likely represents atelectasis or
scarring. Otherwise, no focal consolidation, pleural effusion or pneumothorax
is identified.
IMPRESSION: No evidence of an acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CP
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 98.0
heartrate: 74.0
resprate: 15.0
o2sat: 94.0
sbp: 140.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ M w/ DM, AFib and HTN who presented to ED ___/
one day of epigastric pain, EKG changes, and a troponin leak
most consistent with Acute Coronary Syndrome: NSTEMI vs missed
STEMI.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiography and balloon angioplasty of the ostium of a
diagonal branch
History of Present Illness:
___ y/o man S/P porcine bioprosthetic aortic valve replacement
___ for rheumatic aortic valve disease) and Streptococcal
endocarditis s/p 6 weeks of ceftriaxone IV via right PICC line
from ___ to ___ with spleenic infarct on ___
treated with an additional 2 weeks of ceftriaxone with repeat
TEE at that time showing resolved bioprosthetic vegetations,
hyperlipidemia, TIA in ___, and bipolar disorder who was
transferred from ___ after evaluation for chest pain
with 2 negative troponin-T values. Per OPAT note, no evidence of
relapsed bacteremia or endovascular infection to date.
Patient has been having exertional chest pain x 3 weeks and in
the past week has started developing chest pain at rest with
mild exertional shortness of breath. He says the pain is worse
at night with a gnawing sensation and that during that day his
chest pain is sparse, lasting ___ seconds of the same quality,
but much less intense compared to night. No history of MI. Per
cardiology at ___ need to obtain a stress echo at
___ and consider aortic valve replacement.
In the ED, initial vitals were: T 97.7 HR 70 BP 128/67 RR 18
SaO2 98% on RA. Labs were significant for negative troponin-T,
D-Dimer to 2661, H&H ___, WBC 11, normal chem-7. Chest CTA
showed moderate right and small left pleural effusions new since
___, right greater than left atelectasis, and no
evidence of pulmonary embolism or aortic abnormality. The
patient was not given anything for chest pain. Vitals prior to
transfer were: T 97.8 HR 70 BP 132/64 RR 16 SaO2 97% on RA. Upon
arrival to the cardiology ward, he was chest pain free, without
shortness of breath, and had no acute complaints.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- rheumatic fever
- Bioprosthetic aortic valve replacement for rheumatic heart
disease with porcine valve ___
- Streptococcuc sanguis endocarditis ___
- history of TIA in ___ - maintained on warfarin since
___ but has been completely reversed in past for surgery,
hematoma, etc.
- bipolar disorder
- PTSD
- cognitive decline
- history of left lower extremity hematoma x2 while
supratherpeutic on warfarin ___
- right cubital tunnel syndrome
- hyperlipidemia
- S/P right carpal tunnel release
- S/P right wrist arthrodesis
- h/o basal cell Ca
- OSA on CPAP
Social History:
___
Family History:
Father with ___ disease and MI in ___. Mother with MI in
___
Physical Exam:
On admission
General: Middle aged white man, alert, oriented, in no acute
distress
Vitals: T 98.3 BP 108/88 HR 94 Wt 77 kg
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Normal S1, mechanical S2. ___ systolic murmur heard best at
RUSB and LLSB
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: CN II-XII intact, ___ strength upper and lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
At discharge
Gen: Pleasant, calm
VS: T 98.1 BP 92-123/36-54 HR ___ RR 18 SaO2 96% on RA
weight: 75.2 <- 75.7 <- 76.6 <- 77.9
I&O: today ___ last 24 hrs 1220/1050
HEENT: No conjunctival pallor. MMM. OP clear.
NECK: Supple, No LAD. JVP above the clavicle while seated
upright.
CV: PMI in ___ intercostal space, mid clavicular line. III/VI
systolic murmur at the base, without radiation to the carotids.
II/IV diastolic murmur noted across precordium.
LUNGS: CTAB--no wheezes, rales, or rhonchi.
ABD: Normal active bowel sounds. Soft, non-tender, not
distended. No HSM.
EXT: warm and well perfused; no clubbing, cyanosis or edema
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. No gross motor or sensory
deficits.
PSYCH: Mood was good and affect was appropriate.
Pertinent Results:
___ 08:40PM BLOOD WBC-11.0* RBC-4.46* Hgb-12.6* Hct-37.9*
MCV-85 MCH-28.3 MCHC-33.2 RDW-14.6 RDWSD-44.2 Plt ___
___ 08:40PM BLOOD Neuts-60.2 ___ Monos-9.6 Eos-2.2
Baso-0.7 Im ___ AbsNeut-6.59* AbsLymp-2.95 AbsMono-1.05*
AbsEos-0.24 AbsBaso-0.08
___ 08:40PM BLOOD Glucose-85 UreaN-22* Creat-1.0 Na-139
K-4.6 Cl-104 HCO3-25 AnGap-15
___ 08:40PM BLOOD Calcium-9.2 Phos-4.6*# Mg-1.9
___ 08:40PM BLOOD D-Dimer-2661*
___ 08:40PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD cTropnT-<0.01
___ 01:55AM BLOOD cTropnT-<0.01
___ 01:40PM BLOOD cTropnT-0.02*
___ 05:26PM BLOOD cTropnT-0.02*
___ 05:02AM BLOOD WBC-10.0 RBC-4.47* Hgb-12.6* Hct-38.3*
MCV-86 MCH-28.2 MCHC-32.9 RDW-15.0 RDWSD-45.8 Plt ___
___ 05:02AM BLOOD ___
___ 05:02AM BLOOD Glucose-87 UreaN-27* Creat-1.1 Na-141
K-4.6 Cl-104 HCO3-28 AnGap-14
___ 05:02AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.2
ECG ___ 6:43:56 ___
Slight baseline artifact. Sinus rhythm. Borderline left
ventricular hypertrophy by voltage criteria. Borderline left
axis deviation suggesting left anterior fascicular block.
Terminal T wave inveresion in leads V1-V5 with slight T wave
inversion in lead aVL. Compared to the previous tracing of
___ left axis deviation and left ventricular hypertrophy are
new. Terminal T wave inversions are also new and may be
secondary to left ventricular hypertrophy, but an ongoing
anterior and possibly lateral ischemic process cannot be
excluded. Clinical correlation is suggested.
Chest CTA ___
The aorta and its major branch vessels are patent, with no
evidence of stenosis, occlusion, dissection, or aneurysmal
formation. There is no evidence of penetrating atherosclerotic
ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental
level, with no evidence of filling defect within the main,
right, left, lobar, segmental or subsegmental pulmonary
arteries. The main and right pulmonary arteries are normal in
caliber, and there is no evidence of right heart strain. There
is a prosthetic aortic valve. Coronary artery calcifications are
of unknown hemodynamic significance.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Moderate right
and small left pleural effusions are new since ___.
Bilateral right greater than left lower lobe atelectasis. There
is no focal consolidation or pulmonary edema. No pneumothorax.
The airways are patent to the subsegmental level.
Limited images of the upper abdomen show a chronic splenic
infarction.
No lytic or blastic osseous lesion suspicious for malignancy
is identified.
There are median sternotomy wires.
IMPRESSION:
1. Moderate right and small left pleural effusions are new since
___.
2. Right greater than left atelectasis.
3. No evidence of pulmonary embolism or aortic abnormality.
Echocardiogram ___
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF=70%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis despite normal leaflet movement. A paravalvular
aortic valve leak is probably present. There is a probable
vegetation on the aortic valve measuring 0.7x0.8cm. The lesion
is very echo dense and adherent to the leaflet. The lesion looks
calcified and could be a healed vegetation from his prior
episode of endocarditis. Degenerative leaflet calcification is
also possible. At least moderate (2+) valvar aortic
regurgitation is seen directed towards the anterior mitral
leaflt with additional paravalvular leak present. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. There is borderline
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve.
IMPRESSION: Well-seated bioprosthetic aortic valve with probable
prosthetic endocarditis which may be a healed vegetation given
degree of calcification (see above). Moderate valvar aortic
regurgitation with more mild paravalvular leak. Increased trans
aortic valve gradients in part due to the high stroke volume
from aortic regurgitation.
Compared with the prior study (images reviewed) of ___ a
probable prosthetic aortic valve vegetation is now seen (versis
degenerative calcification) with significant aortic
regurgitation and high gradients across the valve.
Cardiac catheterization ___
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery: The LMCA is normal.
* Left Anterior Descending: The LAD is normal. The ___ Diagonal
is 70% narrowed at the ostium.
* Circumflex: The Circumflex is normal. The ___ Marginal is
normal.
* Right Coronary Artery: The RCA is normal. The Right PDA is
normal.
Interventional Details
Using a XBLAD 3.5 catheter, the diagonal lesion was crossed
with a long Pro Water wire. There was an enormous amount of
pistoning or to and from movement of the balloon. The ostium was
dilated with a 2.0 balloon to 10 atm with minimal residual
stenosis, no apparent dissections, and TIMI 3 flow.
The patient left the cath lab free of chest pain and in a
clinically stable condition.
Impressions:
1. Successful POBA of an ostial diagonal lesion. Not stented due
to small size, ostial location and pistoning of device during
balloon inflation.
Recommendations
1. Successful POBA, continue medical management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Metoprolol Tartrate 25 mg PO BID
3. OLANZapine 15 mg PO DAILY
4. modafinil 200 mg oral daily
Discharge Medications:
1. OLANZapine 15 mg PO QHS
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. modafinil 200 mg ORAL DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-Coronary artery disease
-Biomarker negative unstable angina
-Prior bioprosthetic porcine aortic valve replacement
-Prior Streptococcus sanguis bioprosthetic aortic valve
endocarditis with
-Possible residual bioprosthetic valve vegetation
-Chest pain
-Gastroesophageal reflux disease
-Hyperlipidemia
-Obstructive sleep apnea
-Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with new hypoxia and elevated D-dimer. Evaluate
for pulmonary emboli.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: ___ MGy-cm
COMPARISON: CTA chest ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain. There is a
prosthetic aortic valve. Coronary artery calcifications are of unknown
hemodynamic significance.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Moderate right and small left
pleural effusions are new since ___. Bilateral right greater than
left lower lobe atelectasis. There is no focal consolidation or pulmonary
edema. No pneumothorax. The airways are patent to the subsegmental level.
Limited images of the upper abdomen show a chronic splenic infarction..
No lytic or blastic osseous lesion suspicious for malignancy is identified.
There are median sternotomy wires.
IMPRESSION:
1. Moderate right and small left pleural effusions are new since ___.
2. Right greater than left atelectasis.
3. No evidence of pulmonary embolism or aortic abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with CHEST PAIN NOS
temperature: 97.7
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 128.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ y/o man S/O bioprosthetic porcine aortic valve aortic valve
replacement in ___ for rheumatic valvular heart disease,
Streptococcus sanguis endocarditis s/p ceftriaxone IV via right
PICC line from ___ to ___, hyperlipidemia, TIAs
treated with warfarin until recently stopped, and bipolar
disorder who was transferred from ___ with biomarker
negative unstable angina (chest pain with normal troponin-T) for
consideration of stress echocardiogram and possibly redo aortic
valve replacement.
# Chest pain: Serial troponin-T values negative and EKG showed
no ischemic changes. Patient reported nighttime pain similar to
previous GERD symptoms, but associated with diaphoresis and
shortness of breath, which is atypical for reflux. Pain may also
be related to recent splenic infarct, although TEE on ___ showed
resolved vegetations, so new embolic infarct seemed unlikely.
Echo on this admission revealed possible aortic vegetation (?
healed vs. subacute) and significant aortic regurgitation.
Coronary angiography showed a moderate 70% stenosis at the
origin of a diagonal that was treated with balloon angioplasty
only (unfavorable anatomic location and small size for
stenting). Post-PCI troponin-T 0.02 twice. He was started on
amlodipine 2.5 daily to prevent recoil, ASA 81 mg daily for CAD,
clopidogrel 75 mg daily after load of 300 mg for post-PCI
secondary prevention, and atorvastatin was increased to 80 mg.
Metoprolol tartrate regimen was simplified to once daily
succinate formulation with a lower dose given concomitant
calcium channel blocker therapy. There was thought to be a GERD
component to his chest pain, and he was started on ranitidine
150 mg BID and Maalox PRN.
# Reassessment of aortic valve with question of surgical
intervention: Cardiac surgery was consulted, and the patient's
primary outpatient cardiologist was involved in the clinical
decision making. Porcine valve placed ___ years ago. Cardiac
surgery felt there was no need for imminent replacement. Cardiac
surgery will follow up on outpatient basis and consider valvular
replacement within the next year.
# OSA - has CPAP but does not use at home.
# Bipolar Disorder - Continued on olanzapine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
egg
Attending: ___.
Chief Complaint:
Right Foot pain
Major Surgical or Invasive Procedure:
I&D of R lower extremity fluid collection on ___.
History of Present Illness:
___ is a ___ year old man w/PMH HIV, Hep C, former IV
drug use, and recurrent abscesses presenting with right foot
pain, erythema, and swelling. Last ___, patient noticed a
small abscess on the dorsum of his R foot. He does not recall
any
trauma to that area. Since then, his foot has become
increasingly
swollen, erythematous, and painful. He has not been able to get
out of bed for the last 2 days because of the pain. He started
taking Bactrim at home which he had from prior episodes of
abscesses which improved the redness and swelling, but not the
pain.
In the ED:
- Initial vital signs were notable for: T 97.9 HR 100 RR 16 Pox
99% RA
- Exam notable for: approximately 2 cm ulceration to the dorsal
aspect of the right foot, with significant surrounding erythema
and edema. The area is markedly tender to palpation. There is no
crepitus. DP and ___ pulses intact. There is an additional small
healing ulceration to the medial right ankle. In addition,
patient has ulceration to the right antecubital fossa, without
surrounding fluctuance, erythema, or tenderness. He has
extensive
scarring and healing nodules to bilateral upper extremities.
- Labs were notable for:
WBC 6.8 Hgb 14.6 Plt 232 SCr 1.1 Lactate 2.1
- Studies performed include:
X-ray R foot
1. Diffuse soft tissue swelling without soft tissue gas. No
radiographic evidence for osteomyelitis.
2. Linear 5 mm radiopaque density plantar to the calcaneocuboid
joint which could reflect dystrophic calcification or a
radiopaque foreign body and clinical correlation is needed.
Blood cultures
- Patient was given:
Vancomycin 1000mg IV
- Consults:
Podiatry - exam consistent with cellulitis, wound is partial
thickness and does not probe deep, no purulent exudate,
recommend
no surgical intervention, IV antibiotics, can consider MRI/US of
R foot to assess for deep fluid collection if not improving on
IV
antibiotics.
Vitals on transfer: T 97.4 HR 93 BP 148/72 Pox 99% RA
Upon arrival to the floor, patient is without complaint. His
pain
has significantly improved and he believes the swelling in his R
foot has improved as well. Denies fevers, chills, nausea,
vomiting, chest pain, shortness of breath, diarrhea, or dysuria.
Past Medical History:
- Hepatitis C
- HIV
- PTSD
- Anxiety/depression
- Amphetamine abuse
- Sinus tachycardia
- Herpes
- Migraine headaches
- Syphilis
- Streptococcal pharyngitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
================
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 98.6 (Tm 98.6), BP: 131/78, HR: 84, RR: 18, O2 sat:
94%, O2 delivery: Ra, Wt: 191.9 lb/87.05 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: R foot with 2 x 1.5cm ulcerated area with healing
scab, surrounding erythema not extended from prior marking, no
purulent exudate noted. Small circular lesion on medial
malleolus
of R leg.
SKIN: Warm. Multiple ulcerations in different stages of healing,
some scabbed over on bilateral upper extremities, multiple
pustular lesions on R hand.
NEUROLOGIC: Face symmetric, moving all extremities
spontaneously,
AOx3.
DISCHARGE EXAM:
================
98.9 154 / 53 81 18 94 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: R foot with 2 x 1.5cm ulcerated area with healing
scab, surrounding erythema not extended from prior marking, no
purulent exudate noted. Small circular lesion on medial
malleolus
of R leg.
SKIN: Warm. Multiple ulcerations in different stages of healing,
some scabbed over on bilateral upper extremities, multiple
pustular lesions on R hand.
NEUROLOGIC: Face symmetric, moving all extremities
spontaneously,
AOx3.
Pertinent Results:
ADMISSION LABS:
================
___ 12:11PM BLOOD WBC-6.8 RBC-5.11 Hgb-14.6 Hct-44.8 MCV-88
MCH-28.6 MCHC-32.6 RDW-13.4 RDWSD-43.4 Plt ___
___ 12:11PM BLOOD Neuts-64.0 ___ Monos-9.3 Eos-1.3
Baso-0.6 Im ___ AbsNeut-4.36 AbsLymp-1.66 AbsMono-0.63
AbsEos-0.09 AbsBaso-0.04
___ 12:11PM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-141
K-4.8 Cl-105 HCO3-23 AnGap-13
___ 07:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
DISCHARGE LABS:
=================
___ 09:30AM BLOOD WBC-5.9 RBC-5.74 Hgb-16.3 Hct-52.6*
MCV-92 MCH-28.4 MCHC-31.0* RDW-13.9 RDWSD-45.9 Plt ___
___ 09:35AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-140
K-4.9 Cl-105 HCO3-21* AnGap-14
___ 11:45AM BLOOD K-4.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth Every eight hours
as needed Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Twice daily Disp #*19 Tablet Refills:*0
3. Collagenase Ointment 1 Appl TP DAILY
RX *collagenase clostridium histo. [Santyl] 250 unit/gram Daily
Refills:*0
4. Mupirocin Ointment 2% 1 Appl TP BID apply to lesions on
bilateral upper extremities
RX *mupirocin 2 % Twice daily Refills:*0
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Cellulitis of R foot
Secondary diagnosis: Recurrent superficial staph infections of
bilateral upper extremities
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with right foot ulcer/cellulitis// eval underlying
bony changes
TECHNIQUE: Right foot, three views
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation. No cortical destruction to suggest
osteomyelitis. Moderately severe degenerative changes of the first MTP joint
with joint space narrowing, subchondral sclerosis and osteophyte formation.
No suspicious lytic or sclerotic osseous abnormalities. Small plantar and
dorsal calcaneal spurs. Diffuse soft tissue swelling without soft tissue gas.
5 mm linear radiopaque density is seen plantar to the calcaneocuboid joint,
which could reflect a dystrophic calcification or radiopaque foreign body.
IMPRESSION:
1. Diffuse soft tissue swelling without soft tissue gas. No radiographic
evidence for osteomyelitis.
2. Linear 5 mm radiopaque density plantar to the calcaneocuboid joint which
could reflect dystrophic calcification or a radiopaque foreign body and
clinical correlation is needed.
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST RIGHT
INDICATION: ___ year old man with R lower extremity foot infection with eschar
concerning for osteomyelitis.// evaluate for osteomyelitis
TECHNIQUE: Multiplanar images of the right foot were performed with the
administration of intravenous contrast using a mass/infection MR foot
protocol.
COMPARISON: Right foot radiographs on ___
FINDINGS:
There is diffuse soft tissue edema over the dorsal foot, most prominent along
the midfoot underlying soft tissue defect consistent with patient's known
ulcer (07:11). Immediately deep to the wound there is slightly more focal T1
hypointense, STIR slightly hyperintense tissue spanning approximately 3.3 x
3.1 x 0.7 cm without rim enhancement, likely representing phlegmon or necrotic
tissue (1001: 23; 11:11). This phlegmon does not extend down to the level of
the bone.
There is no bone marrow signal abnormality. The interosseous muscles are
normal in signal and bulk. There are mild degenerative changes with spurring
at the first MTP joint. There are otherwise no significant degenerative
changes in the tarsometatarsal (TMT), metatarsophalangeal (MTP), proximal
interphalangeal (PIP), and distal interphalangeal (DIP) joints.There is a
bipartite tibial sesamoid.
The flexor and extensor tendons crossing the foot are intact, with normal
signal, and no evidence of tenosynovitis.
There is no ___ neuroma. There is no enhancing mass.
IMPRESSION:
1. No evidence of osteomyelitis.
2. Diffuse soft tissue edema along the dorsum of the foot with likely phlegmon
underlying the known ulcer along the dorsal midfoot. No organized abscess.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Foot swelling, Wound eval
Diagnosed with Cellulitis of right lower limb
temperature: 97.8
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | ___ is a ___ year old man w/PMH HIV, Hep C treated
with
harvoni, IV drug use (reports use within the last month), and
recurrent abscesses of upper extremities presenting with right
foot pain, erythema, and swelling consistent with cellulitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, elevated troponins
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ___ CAD s/p stent x4 presents for chest pain,
transferred from outside hospital for troponin of 0.09.
ED history and course per MERIT evaluation.
In the ED, he reported that for a few days, he has had
significant issues with lightheadedness. He was noted to be
bradycardic at the outside hospital in the ___. He developed
chest pain on the day of admission that persisted for about 4
hours. He reported his chest pain does not actually feel quite
like prior MI. He reported that in the past it is radiated down
his left arm but tonight it was just in the ___ his chest
was relatively mild at about 3 out of 10. He reported his pain
is worse with inspiration and is not positional or exertional.
He had nausea with this pain and lightheadedness.
___ evaluated patient at 1045 for call by RN that he was
having intermittent "fogginess" and difficulty with speech.
Per MERIT note, the patient related that for the past several
days he had not felt quite himself. Yesterday ___ he reported
he got into a minor fender-bender because he misjudged the
distance to the next car. He reported that this was at a low
speed, coming a stop at a light. He stated that when he arrived
to the ED he was asked his name, and told them ___ He is
a lawyer and states that this is out of character for him. He
also reported that he is having some intermittent difficulty
articulating words, they sound slightly garbled to him.
In addition, he reported crescendo angina over the past several
weeks to months. He tells me that in ___ he had a sharp
stabbing pain in his chest with exercise that subsided with
nitroglycerin. Since then, he has gotten nausea/burping when
increasing his exercise (he exercises nearly daily; reports
nausea/burping when increasing rate on treadmill from 2.0 to
3.7). He denied any chest pain, shortness of breath,
palpitations, radiation of discomfort, or diaphoresis during
this episode.
On exam:
A&O and in NAD
Resp:Lungs CTAB
CV: RRR no murmurs
Neuro: His cranial nerves were tested and are intact. Normal
FnF. Normal ability to name high and low frequency object.
Normal strength. his speech is fluent and words are clearly
articulated.
Regarding his prior cardiac history, reports that he developed
chest pain that radiated down both arms, nausea, vomiting,
diaphoresis while hiking a mountain in ___. He went to a
clinic there, where he had an EKG and lab work and was told that
he did not have a heart attack. He subsequently had a stress
test but was symptomatic so had a cath and had 4 stents placed.
Patient also reports intentional 35 pound weight loss since
___.
In the ED initial vitals were: 97.0 50 100/44 16 100% RA
Labs/studies notable for:
___ Labs (last checked at ___ 01:16
refresh)
___
21:47
15.3
6.5 >---< 138
43.7
N:54.5 L:33.7 M:8.5 E:2.5 Bas:0.6 Absneut:3.53 Abslymp:2.18
Absmono:0.55 Abseos:0.16 Absbaso:0.04
141 100 27
------------< 82 GFR= > 60
4.9 26 0.91
Ca: 9.5 Mg: 2.39
CK-MB: 3.00 Trop-T: 0.091
At ___ Main ___
13.1
5.8 >-----< 122
38.1
139 104 24
--------------<85 AGap=13
3.9 26 0.7
CK: 79 MB: 2 Trop-T: 0.06 -> 0.04
D-Dimer: 155
Patient was given:
07:03 Clopidogrel 75 mg PO/NG DAILY
07:03 Citalopram 40 mg PO/NG DAILY
07:03 Aspirin 81 mg PO/NG DAILY
07:03 Atorvastatin 80 mg PO/NG QPM Start: Today -
___,
Got full-dose ASA PTA.
Heparin was held ___ lack of clear ACS diagnosis.
Per cards fellow, as seen in the ED:
___ YO M w/ CAD s/p multiple PCI who presents with
lightheadedness and dizziness over the last few days, found to
have HR in the low ___ which is a departure from his baseline HR
in the high ___ and ___ noted on prior ECGs and in clinic
visits. He reports mild chest pressure over the last 24 hours
associated with SOB. His EKG is non-ischemic. Overall, his
presentation appears most consistent with symptomatic
bradycardia. His chest pressure with slight troponin elevation
is likely ___ to some degree of demand ischemia in the setting
of bradycardia. Would not heparinize at this time. Otherwise, he
appears stable for the floor given hemodynamic stability."
Plan was made to admit to ___ and monitor on telemetry
Vitals on transfer: 98.1 41 114/84 16 99% RA
The patient corroborates the above story.
He reports that on ___ he was driving home ___ ___ when he felt
a dull pressure (not a sharp pain) in the ___ his chest.
He did not take any nitro as he did not feel a sharp pain. He
Reported he had felt some nausea and upset stomach on the day of
admission. He notes that on the day his chest pain started he
also felt disoriented, getting into a fender bender in the
parking lot at ___ and feeling like he was not able to judge
distance in his car.
He denies true "palpitations" btu does report sensation of chest
pressure and heaviness.
___ days of dizziness and lightheadedness in the morning. He
denies fainting/LOC.
He reports he has been following with Dr ___ ___. He
reports he usually has higher BPs and had not had any issues
with dizziness or lightheadedness/AMS in the past. He reports
his doses of medication (metoprolol) had decreased during his
cardiac rehab/weight loss.
He denies f/c/+ mild nausea, no vomiting.
He reports that when he increases his increases the rigor of
exercise he does sometimes feel indigestion/burping. Denies
cough, denies leg swelling. + PND. + SOB with exercise ("when
I'm pushing myself") ; does reports some tiredness with doing
stairs. Denies hematuria/hematochezia. + report L 10% of vision
visual field loss, bright area of light (3 nights in a row) ~1
month ago and has not occurred since and new floaters ___
years) and ringing in the ears (long standing problem). Denies
focal weakness.
Past Medical History:
1. CARDIAC RISK FACTORS
1. Coronary artery disease status post LCx stenting, residual
RCA disease
2. Obstructive sleep apnea
3. Borderline hypertension controlled by lifestyle
4. Mixed dyslipidemia ___ 248, HDL 54, LDL 157, ___ 183)
2. CARDIAC HISTORY
1. Coronary angiogram ___ distal LAD, subtotal LCx
occlusion status post 4 2.25 mm resolute stents complicated with
edge dissection. 95% focal mid to distal RPDA
2. TTE ___ mild, LVEF 55%, basal inferior HK, 1+ MR
3. ETT ___ minutes MB, ___ MBT, angina, nonspecific ST-T
OTHER PERTINENT PAST MEDICAL HISTORY:
Erectile dysfunction
Social History:
___
Family History:
Dad with an MI in his ___. CHF mom and dad.
Physical Exam:
PHYSICAL EXAMINATION AT ADMISSION:
VS: 1646 98.9 PO 100 / 61 L Lying 42 18 96 RA
GENERAL: WDWN M, in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI grossly. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple, JVP not elevated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. bradycardic, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: strength ___ in UE and ___ bilaterally. CN II-XII grossly
intact
PHYSICAL EXAM AT DISCHARGE
VS: 0306 97.5 PO 125 / 74 L Lying 59 20 96 RA
GENERAL: WDWN M, in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI grossly. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
PERRLA
NECK: Supple , no carotid bruit bilaterally
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. bradycardic, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. NABS
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: moving all extremities, following commands, CN II-XII
grossly intact
Pertinent Results:
PERTINENT LABS
===============
___ 02:07AM BLOOD WBC-5.8 RBC-3.85* Hgb-13.1* Hct-38.1*
MCV-99* MCH-34.0* MCHC-34.4 RDW-12.4 RDWSD-44.8 Plt ___
___ 07:25PM BLOOD WBC-5.7 RBC-3.95* Hgb-13.7 Hct-38.9*
MCV-99* MCH-34.7* MCHC-35.2 RDW-12.4 RDWSD-44.6 Plt ___
___ 08:15AM BLOOD WBC-5.3 RBC-4.34* Hgb-14.7 Hct-42.7
MCV-98 MCH-33.9* MCHC-34.4 RDW-12.0 RDWSD-43.6 Plt ___
___ 06:10AM BLOOD WBC-5.0 RBC-4.24* Hgb-14.4 Hct-41.7
MCV-98 MCH-34.0* MCHC-34.5 RDW-12.3 RDWSD-44.7 Plt ___
___ 08:15AM BLOOD ___ PTT-29.2 ___
___ 02:07AM BLOOD Glucose-85 UreaN-24* Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-26 AnGap-13
___ 07:25PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
___ 08:15AM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-141
K-4.6 Cl-102 HCO3-29 AnGap-15
___ 06:10AM BLOOD Glucose-77 UreaN-17 Creat-0.8 Na-143
K-4.5 Cl-102 HCO3-25 AnGap-21*
___ 02:07AM BLOOD ALT-26 AST-27 LD(LDH)-177 CK(CPK)-79
AlkPhos-84 TotBili-1.3
___ 02:07AM BLOOD CK-MB-2 cTropnT-0.06*
___ 07:50AM BLOOD cTropnT-0.04*
___ 07:25PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.3
___ 08:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4
___ 06:10AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.4
___ 02:07AM BLOOD calTIBC-247* Ferritn-___ TRF-190*
___ 02:07AM BLOOD TSH-2.0
Carotid Duplex ___
IMPRESSION:
70-79% stenosis of the left internal carotid artery. Less than
40% stenosis of the right internal carotid artery.
ETT ___
TOTAL EXERCISE TIME: 12.5 % MAX HRT RATE ACHIEVED: 86
SYMPTOMS: ATYPICAL PEAK INTENSITY: ___
ST DEPRESSION: ISCHEMIC PEAK INTENSITY: 1.0 MM STD 0.5-1.0 MM
STD
TIME HR BP RPP
ONSET: ___ MIN EX ___
RESOLUTION: ___ MIN REC 75 94/60 7050
INTERPRETATION: This ___ year old man with a h/o HLD and CAD s/p
PCI
x4 to the LCx in ___ was referred to the lab for evaluation
of chest discomfort and lightheadedness. The patient exercised
for 12.5 minutes of a modified ___ protocol and stopped for
fatigue. The estimated peak MET capacity is 10.6, representing a
good functional capacity for his age. The patient reported to
the lab with a ___ upper right-sided chest burning, which
resolved prior to exercise. During stage III of exercise, the
patient reported a fleeting epigastric twinge, which was again
reported in two separate locations near peak exercise and
different from the symptoms he was being evaluated for. At peak
exercise there was 1.0 mm slowly upsloping to horizontal ST
segment depression in leads V2-4 and 0.5-1.0 mm slowly upsloping
to horizontal ST segment depression in leads I and V5. Of note
there was an RSR' noted in lead I at peak exercise, which
resolved at 4 minutes of recovery. These changes albeit less
severe, became slightly downsloping in contour at 3 minutes of
recovery with biphasic T waves and resolved by 15 minutes of
recovery. The rhythm was sinus with rare isolated APBs and one
isolated VPB. Appropriate heart rate response to exercise and
recovery with a blunted blood pressure response to exercise (<30
mmHg increase).
IMPRESSION: Ischemic EKG changes with atypical type symptoms.
Blunted
blood pressure response to exercise. Good functional capacity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Citalopram 40 mg PO DAILY
5. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Citalopram 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Bradycardia
Secondary:
Carotid Artery Stenosis
Coronary Artery Disease
Obstructive Sleep Apnea
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with CAD, symptomatic bradycardia presents with
chest pressure, some transient disorientation. Please evaluate bilateral
carotid arteries
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None.
FINDINGS:
RIGHT:
The right carotid vasculature has mild atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 120 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 69, 95, and 98 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 34 cm/sec.
The ICA/CCA ratio is 0.81.
The external carotid artery has peak systolic velocity of 173 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has significant heterogeneous atherosclerotic
plaque involving the left internal carotid artery.
The peak systolic velocity in the left common carotid artery is 109 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 281, 111, and 59 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 89 cm/sec.
The ICA/CCA ratio is 2.5.
The external carotid artery has peak systolic velocity of 175 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
70-79% stenosis of the left internal carotid artery. Less than 40% stenosis
of the right internal carotid artery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified
temperature: 97.0
heartrate: 50.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 44.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ male with past medical history
notable for CAD s/p 4 stent placement ___, hyperlipidemia,
hypertension, obstructive sleep apnea, and obesity who initially
presented from OSH with chest pain and dizziness with concern
for symptomatic bradycardia.
#Symptomatic Bradycardia:
Patient presented with lightheadedness, dizziness and
disorientation with EKG revealing sinus bradycardia with first
degree AV block. No STE/depressions to suggest ischemia. The
patient's metoprolol was held and his heart rates improved and
he remained stable without significant or long-lasting episodes
of lightheadedness/altered mental status for the ___ prior to
discharge per his report. Please see below for further details
regarding elevated troponin and episode of
confusion/lightheadedness.
#Elevated Troponin
#Coronary Artery Disease
Patient found to have elevated troponin of 0.09 at OSH which
improved to 0.06 and 0.04 upon arrival to ___. Deemed likely
to be demand ischemia in the setting of symptomatic bradycardia
as no STE/depressions and patient was chest pain free upon
arrival to ___. Of note, has known CAD with recent stent x4 in
___ (60% distal LAD, subtotal LCx occlusion status post 4
2.25 mm resolute stents complicated with edge dissection. 95%
focal mid to distal RPDA). Given history of CAD and mildly
elevated troponin, he underwent exercise stress test that
showed: 1.0 mm slowly upsloping to horizontal ST segment
depression in leads V2-4 and 0.5-1.0 mm slowly upsloping to
horizontal ST segment depression in leads I and V5 at peak
exercise. There was an RSR' noted in lead I at peak exercise,
which resolved at 4 minutes of recovery. These changes albeit
less severe, became slightly downsloping in contour at 3 minutes
of recovery with biphasic T waves and resolved by 15 minutes of
recovery. The rhythm was sinus with rare isolated APBs and one
isolated VPB. Appropriate heart rate response to exercise and
recovery with a blunted blood pressure response to exercise (<30
mmHg increase). Given that the patient did not have symptoms
with exercise and was recently cath'd and intervened upon, there
was low suspicion of active ischemia. The patient was continued
on his ASA, atorvastatin, and clopidogrel with plans to
follow-up with Dr. ___ further management.
#Transient neurologic symptoms
Patient reports unclear neurologic symptoms (dysarthria,
disorientation, visual symptoms in the past few months) which
could be related to symptomatic bradycardia/poor cerebral
perfusion but given vascular risk factors, TIA was also a
considered possibility. His neurologic exam was normal at
admission. The patient's symptoms completely resolved upon
arrival to ___. Given risk factors, however, he underwent
bilateral carotid artery Doppler ultrasound which revealed L ICA
70-79% stenosis. Plan to follow-up with vascular surgery for
further management after discharge.
TRANSITIONAL ISSUES
======================
[] metoprolol was stopped at this hospitalization
[] patient was found to have 70-79% L ICA stenosis at this
admission. Outpatient Vascular Surgery follow up has been
arranged. Please continue to monitor these symptoms and continue
outpatient workup
[] please ensure that patient has cardiology follow up with Dr
___ at discharge to determine need for additional
testing/stress testing as an outpatient
[] patient had a mild anemia which improved during his hospital
course. He was noted to have a mild thrombocytopenia. Please
follow up these issues as an outpatient and consider repeat CBC
# CODE: FULL CODE with reasonable trial of life sustaining
treatment
# CONTACT: HCP: ___ (brother) ___
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Byetta / clonidine
Attending: ___.
Chief Complaint:
Lethargy/Altered mental status
Major Surgical or Invasive Procedure:
___: Lumbar Puncture
History of Present Illness:
___ yo F w/ PMHx of DM c/b neuropathy, multiple CVAs, recently
left AMA on ___ brought to ED over ___ concern ___ for
worsening lethargy over the course of the day. She left AMA
after being treated for complicated UTI and hypokalemia. The pt
states that after she left the hospital, she was feeling
improved. But, the day prior to admission, she started feeling
terrible. She stated that she had increased urinary frequency,
foul smelling urine, and discomfort while urinating. She was
also complaining of fatigue and tiredness, fevers to 100 and
chills. Currently, she is complaining of abdominal pain, mostly
from being hungry. She denies any recent IVDU.
In the ED intial vitals were: 84 66/41 97.0 100% RA
She was altered in the ED and difficult to get a history from.
She was started on levaphed for pressure support. She spiked to
102.3 @ 1300 ___. Her BUN/Cr was 37/4.0 and K+ was 2.6. She
was fluid resucitated with 5L NS and given 80mEq of K+
repletion, started on vanc and zosyn. She was weaned off
levaphed by 0800 ___. A head CT was negative for any acute
intracranial pathology. Since she was c/o back pain, and in the
setting elevated ESR and CRP, she had an MRI of her back to r/o
osteo.
Vitals on transfer: 99.2 120/70 80 100% RA
Past Medical History:
#CHF: Diastolic, preserved EF
#CVAs: b/l lacunar infarcts in ___, R cerebellar infarct
___, residual weakness of right side
#DM2: c/b neuropathy, retinopathy, gastroparesis
#HTN
#chronic low back pain
#HCV, no prior treatment
#HBV
#mood disorder (depression, anxiety with psychotic features per
OMR)
#tardive diskinesia
#hiatal hernia
#colon polyps
#cervical degenerative disc disease
#benign thyroid nodules
#s/p cholecystectomy
#s/p c-section
Social History:
___
Family History:
+colon cancer, heart disease, DM, HTN
Physical Exam:
ADMISSION EXAM:
=========================================
Vitals- 98.3 141/60 82 20 100% RA
General- A+Ox2 (oriented to person, place, time - knows year),
poor attention (can't repeat days in reverse)
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, no ROM deficit but pain with neck flexion and
extension, no neck pain with lateral movement, JVP not elevated,
no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, + systolic murmur
Abdomen- +CVAT bilaterally, soft, diffusely TTP, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- + foley draining amber urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function ___ strength on left
___ strength on right, right sided facial weakness, trace
peripheral edema
DISCHARGE EXAM:
=========================================
VS: 98.3 (Tmax 99.4 on ___ 150/70 (SBPs ranging 150-180) 76
100%RA
GEN: Awake, alert, conversant. In no acute distress. Mood stable
during interview
HEENT: PERRL. MMM. No oral lesions.
CARDIO: RRR. No murmur appreciated.
LUNGS: CTA b/l.
ABD: BS+. Soft, nontender, nondistended.
EXT: No ___ edema. Dry skin on LEs.
Pertinent Results:
ADMISSION LABS:
========================================
___ 03:53PM LACTATE-1.2
___ 03:46PM GLUCOSE-158* UREA N-23* CREAT-1.3*#
SODIUM-140 POTASSIUM-2.7* CHLORIDE-109* TOTAL CO2-22 ANION
GAP-12
___ 03:46PM cTropnT-0.02*
___ 03:46PM CALCIUM-7.3* PHOSPHATE-2.0* MAGNESIUM-1.3*
___ 03:46PM CRP-15.9*
___ 03:46PM WBC-5.1 RBC-3.27* HGB-8.0* HCT-25.7* MCV-79*
MCH-24.4* MCHC-31.1 RDW-15.5
___ 03:46PM NEUTS-59.5 ___ MONOS-4.9 EOS-6.3*
BASOS-0.4
___ 03:46PM PLT COUNT-133*
___ 03:46PM SED RATE-40*
___ 08:15PM URINE HOURS-RANDOM
___ 08:15PM URINE UHOLD-HOLD
___ 08:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 08:15PM URINE RBC-3* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:15PM URINE HYALINE-12*
___ 08:15PM URINE AMORPH-OCC
___ 08:15PM URINE MUCOUS-RARE
___ 06:06PM GLUCOSE-114* UREA N-37* CREAT-4.0* SODIUM-139
POTASSIUM-2.6* CHLORIDE-99 TOTAL CO2-25 ANION GAP-18
___ 06:06PM estGFR-Using this
___ 06:06PM LIPASE-29
___ 06:06PM CK-MB-5 proBNP-1813*
___ 06:06PM cTropnT-0.06*
___ 06:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:06PM GLUCOSE-93 LACTATE-2.4* NA+-141 K+-2.6*
CL--96 TCO2-26
___ 06:06PM WBC-9.9 RBC-4.14* HGB-10.0* HCT-31.8* MCV-77*
MCH-24.2* MCHC-31.6 RDW-15.8*
___ 06:06PM ___ PTT-26.2 ___
___ 06:06PM PLT COUNT-238
___ 06:06PM ___
DISCHARGE LABS:
========================================
___ 07:20AM BLOOD WBC-6.3 RBC-3.62* Hgb-8.7* Hct-28.5*
MCV-79* MCH-24.1* MCHC-30.5* RDW-15.7* Plt ___
___ 07:20AM BLOOD Glucose-155* UreaN-15 Creat-0.8 Na-144
K-4.2 Cl-109* HCO3-28 AnGap-11
___ 07:20AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6
PERTINENT IMAGING:
========================================
MRI without contrast (___):
IMPRESSION:
Severe motion artifact degrades the images. Evaluation of
abscess is limited in the absence of intravenous contrast.
Within the confines of these limitations:
1. Abnormal bone marrow signal involving the inferior endplate
of T7, entire T8 vertebral body and superior endplate of T9,
with also abnormal disc spaces at T7-T8 and T8-T9. No definite
evidence of epidural or intradural extension or paraspinal
abscess seen. No definite cord signal abnormality identified.
Findings are concerning for discitis/osteomyelitis, although
appearance could also represent degenerative disease. Further
evaluation with MRI of the thoracic spine with contrast and
without motion may be performed if clinically dicated.
2. Abnormal signal within the posterior right upper lobe, which
is not
adequately evaluated with this study and may represent
pneumonia.
Renal US (___):
IMPRESSION:
1. Normal sonographic appearance of the kidneys.
2. Right renal simple cysts.
IMPRESSION:
1. Subtle ground-glass opacities are less extensive than seen on
MRI of the thoracic spine of one day earlier. This could
potentially represent an acute aspiration event given apparent
rapid improvement. However, a followup chest CT in three months
would be helpful to document resolution and to exclude other
potential causes of ground-glass opacity including alveolitis,
hemorrhage, infection and lung adenocarcinoma. At that time, a
4-mm diameter ground-glass nodule in the right lower lobe
posteriorly may also be reassessed.
2.Subpleural distribution of fibrotic lung disease, which may
represent a fibrotic subtype of NSIP or UIP.
3. Similar appearance of renal cysts which have been
characterized as simple cysts on recent renal ultrasound
examination. Unchanged appearance of the thyroid gland, for
which a one- to two-year followup ultrasound was recommended at
the time of the most recent thyroid ultrasound exam.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Aripiprazole 15 mg PO QAM
3. Aspirin 325 mg PO DAILY
4. Citalopram 40 mg PO QAM
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO QHS:PRN pain
8. Lisinopril 40 mg PO DAILY
9. Metoprolol Succinate XL 150 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Senna 2 TAB PO BID
14. Vitamin D 1000 UNIT PO DAILY
15. QUEtiapine Fumarate 300 mg PO DAILY
16. NovoLOG (insulin aspart) 100 unit/mL Subcutaneous PRN BG>180
17. Mupirocin Cream 2% 1 Appl TP TID
18. Mirtazapine 7.5 mg PO HS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aripiprazole 15 mg PO QAM
3. Aspirin 325 mg PO DAILY
4. Citalopram 40 mg PO QAM
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 300 mg PO QHS:PRN pain
8. Lisinopril 40 mg PO DAILY
9. Metoprolol Succinate XL 150 mg PO DAILY
10. Mirtazapine 7.5 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. Mupirocin Cream 2% 1 Appl TP TID
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. QUEtiapine Fumarate 300 mg PO DAILY
16. Senna 2 TAB PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. NovoLOG (insulin aspart) 100 unit/mL Subcutaneous PRN BG>180
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# PRIMARY: hypotension, likely sepsis
# SECONDARY: prior stroke, mood disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with lower back pain, fever, IV drug abuse.
Evaluate for presence of epidural abscess.
TECHNIQUE: Multiplanar, multi sequence MRI of the thoracic spine was
performed without intravenous contrast administration.
COMPARISON: None.
FINDINGS:
There is severe motion artifact which degrades the images. Evaluation of
abscess is limited in the absence of intravenous contrast. Within the
confines of these limitations:
There is abnormal bone marrow signal involving the inferior endplate of T7,
complete T8 vertebral body and superior endplate of T9, and involving the
T7-T8 and T8-T9 disc spaces. There is no evidence of intradural extension or
paraspinal mass lesions. There are multilevel mild diffuse small posterior
disc bulges throughout the mid to lower thoracic spine, including at these
levels. There is no definite evidence of cord compression. No definite cord
signal abnormality is identified, although evaluation is limited by motion
artifact. There is no definite evidence of epidural or paraspinal abscess.
Vertebral body alignment and height is preserved. There is a Schmorl node at
the inferior endplate of T7.
There is abnormal signal within the posterior right upper lobe.
IMPRESSION:
Severe motion artifact degrades the images. Evaluation of abscess is limited
in the absence of intravenous contrast. Within the confines of these
limitations:
1. Abnormal bone marrow signal involving the inferior endplate of T7, entire
T8 vertebral body and superior endplate of T9, with also abnormal disc spaces
at T7-T8 and T8-T9. No definite evidence of epidural or intradural extension
or paraspinal abscess seen. No definite cord signal abnormality identified.
Findings are concerning for discitis/osteomyelitis, although appearance could
also represent degenerative disease. Further evaluation with MRI of the
thoracic spine with contrast and without motion may be performed if clinically
indicated.
2. Abnormal signal within the posterior right upper lobe, which is not
adequately evaluated with this study and may represent pneumonia.
Dr. ___ these findings by phone at the time the findings
were made, with Dr. ___, at 09:20 on ___.
Dr. ___ additional findings of right upper lobe
consolidation by phone after reviewing with attending, with Dr. ___
(___), at 1:55 pm on ___.
Radiology Report
HISTORY: CVA with hypotension, fever, CVA tenderness, and UTI. Evaluate for
pyelonephritis, renal abscess.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the bilateral
kidneys were performed.
___ CT abdomen and pelvis.
FINDINGS:
The right kidney is normal in appearance with normal echogenicity and
parenchymal thickness. There is no solid mass, hydronephrosis, or calculus.
There is normal color Doppler vascularity. In the upper pole is a 4.5 x 4 x
3.4 cm simple cyst. In the mid pole is a 2.4 x 2.7 x 2.2 cm simple cyst.
There is no evidence of fluid collection to suggest renal abscess.
The left kidney is normal in size, cortical thickness, and echogenicity. No
solid mass, hydronephrosis, or calculus is identified. There is normal color
Doppler vascularity. There is no fluid collection to suggest a renal abscess.
The urinary bladder is decompressed via Foley catheter.
IMPRESSION:
1. Normal sonographic appearance of the kidneys.
2. Right renal simple cysts.
Radiology Report
HISTORY: Fever, lethargy, hypotension.
TECHNIQUE: Informed consent was obtained after explaining the indications,
risks, and alternative management.
The patient was brought to the fluoroscopic suite and placed prone on the
table in a prone position. The skin overlying the midline lower back was
prepped and draped with aseptic precautions. After timeout was performed, 1%
lidocaine was used for local anesthesia. A 20 gauge spinal needle was used to
access the subarachnoid space at the L4-L5 level under fluoroscopic guidance.
A needle is seen traversing the lower lumbar spine into the subarachnoid
space.
CSF return was controlled and multiple vials of CSF were collected by gravity.
Approximately 10 cc of clear CSF were collected and sent for analysis.
The patient tolerated the procedure well without new complaints.
IMPRESSION:
Successful fluoroscopically guided lumbar puncture. The samples were sent for
routine laboratory analysis as requested by referring physician.
Radiology Report
MR OF THE THORACIC SPINE WITHOUT CONTRAST, ___
HISTORY: ___ female with history of IVDU, CVA, presents hypotensive
febrile with new back pain and prior MR showing "?osteo"; rule out epidural
abscess, osteomyelitis or discitis.
TECHNIQUE: Routine ___ non-enhanced MR examination of the thoracic spine,
including sagittal STIR FSE sequence, was performed.
Apparently, the non-enhanced nature of the study was discussed with Dr. ___
___ per the requisition).
FINDINGS: The study is compared with the very recent non-enhanced study dated
___, as well as the radiographs dated ___.
As on the recent study, there is an abnormal appearance to the T7 inferior
endplate, as well as the T8 and T9 vertebrae. However, the T7 and T8
vertebral signal abnormality is largely corresponding T1-hyper- and T2-
hypointensity with little in the way of STIR-hyperintensity, an overall
appearance suggestive of a mixture ___ types II and III change, related
to the marked degeneration of the intervening discs, which also demonstrate
prominent vacuum phenomenon. Of note, the intervening discs do not
demonstrate abnormal T2-/STIR-hyperintensity to suggest fluidic content, and
there is no evidence of cortical destruction involving the endplates,
themselves.
There is moderately severe STIR-hyperintensity within much of the central
portion of the T9 vertebral body and its inferior endplate, as before;
however, its distribution, as well as the integrity of the adjacent endplate
cortex suggests earlier, ___ type I discogenic change related to the
slightly less advanced degeneration of the T9-10 disc. There has been no
significant change in this overall appearance over the relatively short
interval, and no new thoracic vertebral bone marrow signal abnormality is
identified elsewhere.
The thoracic spinal cord is normal in caliber and intrinsic signal intensity
through the conus medullaris, which is normal in morphology and terminates at
the mid-L1 level, as before. As before, there is multilevel degenerative disc
and endplate disease in the imaged lower cervical and the thoracic spine.
These findings are most marked at the T7-8 through T9-10 levels, above, where
broad-based disc-endplate spondylotic ridges efface the ventral thecal sac
remodeling that aspect of the spinal cord, as before. Similar, but less
marked changes are also apparent at the T4-5 through T6-7, and the T10-11 and
T11-12 levels. There is also cervical spondylosis with prominent central disc
herniations at the C6-7 and C7-T1 levels with ventral canal narrowing, as on
the CT examination of ___.
The evaluation of the paraspinal and epidural soft tissues is quite limited in
the absence of intravenous contrast, but there is no finding to specifically
suggest fluid collection at these sites. There is abundant grouped fluid in
the deep dorsal subcutaneous soft tissues superficial to the supraspinous
ligament, from the T12 through the L2 level, with the inferior extent, not
included in the imaging volume. This is of uncertain significance, but may
simply reflect dependent edema. Finally, again demonstrated is a patchy
airspace process involving the dependent aspect of the right upper lobe, as on
the recent MR study, which may reflect pneumonic infiltrate. Also noted are
at least two exophytic cysts in the right kidney, better evaluated on the
recent sonogram of ___.
IMPRESSION: Again, this study is somewhat limited by the lack of intravenous
contrast, with no rationale provided in the accompanying "paperwork" (and
patient has normal renal functio,n with BUN 15, creatinine 0.8), with:
1. No significant change from the very recent non-enhanced MR examination
with likely discogenic vertebral bone marrow signal abnormalities involving
the T7 through T9 vertebrae, as detailed above. Specifically, again there is
no abnormal T2-/STIR-hyperintensity involving the intervening discs or
evidence of frank endplate destruction to specifically suggest the
discitis-osteomyelitis complex.
2. Multilevel disc-endplate spondylotic ridges, particularly at the
mid-thoracic levels above, with ventral canal narrowing and cord remodeling,
as before.
3. Normal thoracic spinal cord caliber and signal intensity through the conus
medullaris.
4. Extensive airspace process involving the dependent aspects of the right
upper lobe, as on the recent MR; pneumonic infiltrate is a definite
consideration and should be correlated clinically.
5. Abundant grouped fluid in the deep dorsal subcutaneous soft tissues from
the T12 through L2 level, incompletely imaged. While this may simply
represent dependent edema, again, the finding should be correlated clinically.
6. Known right renal simple cysts.
Radiology Report
PA AND LATERAL CHEST FILM ___ AT 14:12
CLINICAL INDICATION: ___ with CVA, now with fever and hypotension,
question pneumonia.
Comparison is made to the patient's prior study of ___.
PA and lateral views of the chest ___ at 14:12 are submitted.
IMPRESSION:
Overall lung volumes have improved and there is resolution of the previously
seen pulmonary edema. There are residual streaky bibasilar opacities likely
reflecting atelectasis or scarring. No focal airspace consolidation is seen
to suggest pneumonia. Overall cardiac and mediastinal contours are stable
with the heart being mildly enlarged. There are marked degenerative changes
in the thoracic spine. No pneumothorax.
Radiology Report
CT CHEST DATED ___.
COMPARISON: MRI of the spine of ___, CTA of the chest ___, MRI of the thoracic spine of ___, and chest radiograph of
___.
TECHNIQUE: Volumetric, multidetector CT of the chest was performed without
intravenous or oral contrast administration. Images are presented for display
in the axial plane at 5-mm and 1-mm collimation. A series of multiplanar
reformation images were also submitted for review.
FINDINGS: Multiple patchy foci of ground-glass opacification are present in
the right upper lobe involving the apex and posterior portion of the lobe.
The extent of lung parenchymal opacification is less than expected based on
the MRI findings.
Assessment of the remainder of the lungs is remarkable for a subpleural
distribution of interstitial lung abnormalities characterized by extensive
reticulation, traction bronchiectasis and bronchiolectasis and minimal
honeycombing. This involves the upper, mid and lower lungs bilaterally.
These findings are difficult to compare to the prior chest CTA study due to
technical difference between the exams, but the findings have apparently
evolved over time, and were previously more ground-glass in appearance. A
4-mm diameter ground-glass nodule in the right lower lobe posteriorly (221, 5)
is apparently new, but could have potentially been obscured on the previous
study due to respiratory motion and relatively expiratory phase of
respiration.
In addition to interstitial lung disease, mild paraseptal emphysema is also
demonstrated with upper lobe predominance.
The thyroid gland is enlarged and heterogeneous with a dominant low-density
lesion in the posterior portion of the right lobe measuring about 1.2 cm.
There are no enlarged mediastinal or hilar lymph nodes. Heart size is normal,
and a small pericardial effusion is present, possibly physiologic. There are
no pleural effusions.
Exam was not specifically tailored to evaluate the subdiaphragmatic region,
but incompletely imaged cystic lesions in the upper pole portion of the right
kidney are similar in appearance to the prior CTA.
There are no suspicious lytic or blastic skeletal lesions.
IMPRESSION:
1. Subtle ground-glass opacities are less extensive than seen on MRI of the
thoracic spine of one day earlier. This could potentially represent an acute
aspiration event given apparent rapid improvement. However, a followup chest
CT in three months would be helpful to document resolution and to exclude
other potential causes of ground-glass opacity including alveolitis,
hemorrhage, infection and lung adenocarcinoma. At that time, a 4-mm diameter
ground-glass nodule in the right lower lobe posteriorly may also be
reassessed.
2. Subpleural distribution of fibrotic lung disease, which may represent a
fibrotic subtype of NSIP or UIP.
3. Similar appearance of renal cysts which have been characterized as simple
cysts on recent renal ultrasound examination. Unchanged appearance of the
thyroid gland, for which a one- to two-year followup ultrasound was
recommended at the time of the most recent thyroid ultrasound exam.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with SEPTICEMIA NOS, URIN TRACT INFECTION NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | PRIMARY REASON FOR HOSPITALIZATION:
======================================================
___ yo F with history of CVA and dCHF and recent discharge AMA
was brought to ED with increasing lethargy and found to be
hypotensive (SBPs in the ___, initially requiring pressors and
5L fluids. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
methimazole / Penicillins / amoxicillin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O hypertension, NSVT who presents with cough and
chest pain.
For the past 2 weeks she has been having a cough (reports
feeling like she had "the flu") and now has 3 days of left
lateral chest pain radiating to the back that is worse with
coughing and deep inspiration. She also notes that her chest is
tender to palpation. Along with the chest pain, she reports
dizziness when she stands and walks, along with palpitations.
The dizziness and palpitations are not specifically associated
with chest pain. She has previously experienced the palpitations
and dizziness. In ___, she reported these symptoms to her PCP.
She was noted to have brief NSVT during her symptoms. Stress
echocardiogram was positive. She reportedly then underwent
cardiac catheterization, which she and daughter say was normal.
She was started on metoprolol and has not had recurrence of
palpitations until 3 days ago. She otherwise denies fevers,
chills, rhinorrhea/nasal congestion, vomiting, abdominal pain,
diarrhea, or recent trauma.
She arrived to the ED in atrial fibrillation with rapid
ventricular rate, for which she was given diltiazem 10 mg x 2 IV
and diltiazem 30 mg IV. Rates improved to 100s-110s. Initial
vitals were: T 98, VR 110, BP 115/77, RR 18, SaO2 96% on RA. EKG
atrial fibrillation with VR 84 bpm, diffuse T wave inversions
V1-V6 as well as inferior leads. She was noted to have JVP ~9 cm
and bilateral pitting edema. She was seen by the cardiology
fellow in ED, who recommended admission to ___ for
some diuresis and rate control. Labs/studies notable for:
Hgb/Hct 16.2/49.3, WBC 11.9 INR 1.2 Troponin-T < 0.01 x2, proBNP
4924 lactate 2.6. Patient was also given NS 500 mL, aspirin 324
mg po, metoprolol tartrate 25 mg X 2. Vitals on transfer: T
99.3, VR 111, BP 120/98, RR 18, SaO2 100% on RA.
On the floor, she reports that she is only having chest pain
when she pushes on her chest wall under her left breast or when
she coughs. Currently without palpitations, shortness of breath,
orthopnea, PND. Does endorse peripheral edema over the last
week. Has not weighed herself. Of note, she was interviewed with
___ interpreter over the phone with some difficulty in
understanding and answering questions appropriately. REVIEW OF
SYSTEMS: As per HPI
Past Medical History:
1. CAD RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- NSVT
3. OTHER PAST MEDICAL HISTORY
- OSA
- Right inguinal history, s/p repair
- Superficial thrombophlebitis
- Vitamin D deficiency
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
On admission
GENERAL: well-appearing elderly white woman, lying at 30
degrees, in NAD. Alert. Mood, affect appropriate.
VS: T 99.1, BP 103/79, VR 52, RR 20, SpO2 92% on RA
Weight: 57.4 kg / 126.54 lbs
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. No
pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP 8-10 cm.
CARDIAC: Irregularly irregular. Tachycardic. Normal S1+S2. No
murmurs, rubs, or gallops.
LUNGS: Mildly tender to palpation under left breast. Bibasilar
crackles. No wheezes or rhonchi.
ABDOMEN: Non-distended, soft, non-tender.
EXTREMITIES: Warm and well perfused. No pitting edema. Palpable
distal pulses bilaterally.
SKIN: No significant skin lesions or rashes.
At discharge
GENERAL: Well-appearing lady, sitting up, in NAD. Alert. Mood,
affect appropriate.
T 98.2 BP 110/66 HR 93 RR 18 SaO2 92%
NECK: Supple. JVP not elevated.
CARDIAC: Irregularly irregular. Normal S1+S2. No murmurs, rubs,
or gallops. No chest wall tenderness to palpation.
LUNGS: Left basilar crackles, Right lung clear. No wheezes or
rhonchi.
ABDOMEN: Non-distended, soft, non-tender.
EXTREMITIES: Warm and well perfused. No pitting edema.
Pertinent Results:
___ 01:20AM BLOOD WBC-11.9* RBC-5.02 Hgb-16.2* Hct-49.3*
MCV-98 MCH-32.3* MCHC-32.9 RDW-14.6 RDWSD-52.5* Plt ___
___ 01:20AM BLOOD Neuts-78.2* Lymphs-12.6* Monos-8.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.27* AbsLymp-1.49
AbsMono-1.01* AbsEos-0.00* AbsBaso-0.04
___ 01:20AM BLOOD ___ PTT-26.1 ___
___ 11:30AM BLOOD Glucose-93 UreaN-18 Creat-0.5 Na-142
K-3.6 Cl-112* HCO3-17* AnGap-13
___ 11:30AM BLOOD ALT-18 AST-23 TotBili-0.7
___ 01:20 cTropnT-<0.01
___ 11:30AM BLOOD cTropnT-<0.01 proBNP-4924*
___ 11:30AM BLOOD TSH-2.4
___ 10:29AM BLOOD Lactate-2.6*
___ 02:10 CK-MB<1 cTropnT-<0.01
___ 07:05 CK-MB<1 cTropnT-<0.01
___ 13:00 CK-MB<1 cTropnT-<0.01
Discharge Labs:
___ 06:43AM BLOOD WBC-6.3 RBC-5.23* Hgb-16.3* Hct-51.7*
MCV-99* MCH-31.2 MCHC-31.5* RDW-14.1 RDWSD-51.1* Plt ___
___ 06:43AM BLOOD ___ PTT-40.1* ___
___ 06:43AM BLOOD Glucose-99 UreaN-20 Creat-0.7 Na-140
K-5.5* Cl-99 HCO3-27 AnGap-14
___ 06:43AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
___ 01:15PM BLOOD K-4.9
___ Echocardiogram
The left atrial volume index is severely increased. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = 20 %) with regional variation.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is mildly dilated
with severe global free wall hypokinesis. 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. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
___ CHEST (PORTABLE AP):
AP portable upright view of the chest. New from prior are
bibasilar effusions and atelectasis. Pleural effusions are small
bilaterally. Cardiomediastinal silhouette is stably prominent.
Hila appear slightly engorged. No frank edema. No pneumothorax.
Bony structures are intact. Overlying EKG leads are present.
___ BILAT LOWER EXT VEINS:
There is normal compressibility, flow, and augmentation of the
bilateral common femoral, femoral, and popliteal veins. A right
posterior tibial vein is noncompressible with no demonstrated
flow, consistent with acute DVT. Compressibility is
demonstrated in the calf veins of the left leg.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION: Positive right calf acute deep vein thrombosis in at
least one of the paired posterior tibial veins.
___ CT ABD & PELVIS, CHEST WITH CONTRAST:
THORACIC INLET: The thyroid is unremarkable. There are no
enlarged supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest
measuring 4 mm. There are no enlarged hilar lymph nodes. There
is approximately 4.8 x 2.7 cm hypodense lesion within the right
atrium (series 303, 121), most likely represents a thrombus or a
mass.
LUNG: There is no evidence of pulmonary edema. No obvious
pulmonary nodules are seen. There are small bilateral pleural
effusions left greater than right with bibasilar atelectasis.
Consolidative opacity contouring the heart in the left lower
lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL: Review of bones shows degenerative changes
involving the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are
unremarkable
IMPRESSION:
large 4.8 x 2.7 cm hypodense lesion within the right atrium
could represent a thrombosed however mass cannot be excluded.
Correlation with ECHO and/or further evaluation with an MRI may
be helpful for to distinguish between the 2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left
lower lobe most likely represents subsegmental atelectasis.
___ Tranesophageal echocardiogram Final Report:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast is
seen in the body of the right
atrium. Mild spontaneous echo contrast is seen in the right
atrial appendage. A large, 3 x 1.9 cm ovoid echodensity (likely
thrombus) is seen in the right atrial appendage. There is no
evidence for an atrial septal defect by 2D/color Doppler. Global
left ventricular systolic function is moderately depressed.
There are no aortic arch atheroma with no atheroma in the
descending aorta. The aortic valve leaflets (3) appear
structurally normal. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is mild [1+] aortic
regurgitation. The mitral leaflets appear structurally normal
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
2. Digoxin 0.125 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*0
3. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
4. Furosemide 60 mg PO DAILY
RX *furosemide 40 mg 1.5 tablet(s) by mouth once a day Disp #*45
Tablet Refills:*0
5. Metoprolol Succinate XL 200 mg PO QHS
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Atrial fibrillation, paroxysmal, with rapid ventricular rate
-Acute left ventricular systolic heart failure with reduced
ejection fraction
-Right atrial thrombus
-Right calf acute deep vein thrombosis
-Hypertension
-Hyperkalemia
-Musculoskeletal chest pain
-Escherichia coli urinary tract infection
-Vitamin D deficiency
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 SOB, chest pain and tachycardia// ?pulm edema, pna,
cardiomegaly
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. New from prior are bibasilar effusions
and atelectasis. Pleural effusions are small bilaterally. Cardiomediastinal
silhouette is stably prominent. Hila appear slightly engorged. No frank
edema. No pneumothorax. Bony structures are intact. Overlying EKG leads are
present.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ yo woman with AFib with RVR and R atrial appendage thrombus//
Pt has RA thrombus, ?embolism from 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.
A right posterior tibial vein is noncompressible with no demonstrated flow,
consistent with acute DVT. Compressibility is demonstrated in the calf veins
of the left leg.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Positive right calf acute deep vein thrombosis in at least one of the paired
posterior tibial veins.
NOTIFICATION: The findings were discussed with ___. ___ , ___. by ___.
___, M.D. on the telephone on ___ at 4:49 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST
INDICATION: ___ year old woman with AFib RVR, unable to undergo DCCV as TEE
showed thrombus in RA; ___ shows DVT; not up to date on cancer screening,
please eval for evidence of malignancy// any evidence of malignancy
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest measuring 4
mm. There are no enlarged hilar lymph nodes. There is approximately 4.8 x
2.7 cm hypodense lesion within the right atrium (series 303, 121), most likely
represents a thrombus or a mass.
LUNG: There is no evidence of pulmonary edema. No obvious pulmonary nodules
are seen. There are small bilateral pleural effusions left greater than right
with bibasilar atelectasis. Consolidative opacity contouring the heart in the
left lower lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable
IMPRESSION:
Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a
thrombosed however mass cannot be excluded. Correlation with ECHO and/or
further evaluation with an MRI may be helpful for to distinguish between the
2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left lower lobe most
likely represents subsegmental atelectasis.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST
INDICATION: ___ year old woman with AFib RVR, unable to undergo DCCV as TEE
showed thrombus in RA; ___ shows DVT; not up to date on cancer screening,
please eval for evidence of malignancy// any evidence of malignancy
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 2.1 s, 28.2 cm; CTDIvol = 6.3 mGy (Body) DLP = 176.1
mGy-cm.
2) Spiral Acquisition 4.9 s, 65.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 474.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 28.7 cm; CTDIvol = 6.3 mGy (Body) DLP = 181.1
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 847 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are small mediastinal lymph nodes the largest measuring 4
mm. There are no enlarged hilar lymph nodes. There is approximately 4.8 x
2.7 cm hypodense lesion within the right atrium (series 303, 121), most likely
represents a thrombus or a mass.
LUNG: There is no evidence of pulmonary edema. No obvious pulmonary nodules
are seen. There are small bilateral pleural effusions left greater than right
with bibasilar atelectasis. Consolidative opacity contouring the heart in the
left lower lobe (303, 147) shows uniform enhancement and could represent
subsegmental atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine. Bones are osteopenic.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable
IMPRESSION:
Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a
thrombosed however mass cannot be excluded. Correlation with ECHO and/or
further evaluation with an MRI may be helpful for to distinguish between the
2.
Small bilateral pleural effusions with bibasilar atelectasis.
No evidence of a pneumonia. Consolidative opacity in the left lower lobe most
likely represents subsegmental atelectasis.
NOTIFICATION: The findings were discussed with Dr ___, M.D. by
___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: L Chest pain
Diagnosed with Unspecified atrial fibrillation
temperature: 98.0
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 115.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ yo woman with a history of hypertension
who presented with cough and chest pain, found to be in atrial
fibrillation with a rapid ventricular rate and acute HFrEF (LVEF
20%). Chest CT on ___ and then TEE on ___ showed a right atrial
appendage thrombus and so cardioversion was deferred. Lower
extremity ultrasound ___ showed right DVT, but CT torso with
contrast with no signs of malignancy. Her atrial fibrillation
and acute systolic heart failure were medically managed; patient
discharged with PCP and cardiology follow up.
# Atrial fibrillation with RVR: She has no known history of
atrial fibrillation and presented with palpitations for the
prior ~3 days. Unclear precipitant though could be secondary to
recent URI and viral cardiomyopathy; history of negative
coronary angiography in ___, so less likely to be ischemic. Of
note, she complained of palpitations to her PCP in ___,
though unclear whether these were undiagnosed atrial
fibrillation vs. NSVT. She was initially given diltiazem in the
ED, with plan for cardioversion. However, ___ demonstrated RA
thrombus and so cardioversion was deferred given risk of
pulmonary embolus. Additionally, amiodarone was deferred given
20% risk of chemical cardioversion. Therefore atrial
fibrillation was managed medically with rate control and
anticoagulation without attempt at rhythm control. She was
initially difficult to rate control despite therapeutic digoxin
and increasing doses of metoprolol tartrate, ultimately at 50 mg
q6h. Due to persistent tachycardia in the 130s-160s, diltiazem
was initiated on ___ and ultimately uptitrated to 30 mg q6h
with good effect, keeping in mind her depressed LVEF, a relative
contraindication to diltiazem or verapamil. At discharge, she
continued to be in atrial fibrillation but was rate controlled
well, with ventricular rates in the ___ at rest. For rate
control she was discharged on digoxin 0.125 mg every other day
and diltiazem ER 120mg daily. Her home metoprolol succinate dose
was increased from 100mg to 200mg daily. She was anticoagulated
with dabigatran 150 mg bid. She will follow up as outpatient
with Dr. ___ potential outpatient TEE/cardioversion once
anticoagulated x 4 weeks.
# DVT and right atrial appendage thrombus: CT ___ and TEE ___
with 3x1.9cm RA thrombus, ___ ___ with right posterior
tibial DVT. Given that the RA thrombus was nestled against the
cardiac wall and not free-floating, and no signs of extension
from the IVC, it was felt to be likely secondary to atrial
fibrillation rather than an embolus from DVT, IVC, or elsewhere.
The patient was initially started on rivaroxaban 20 mg daily but
was subsequently switched to dabigatran 150 mg BID given
potential for enhanced anticoagulation with BID dosing and
higher potency. She tolerated this well with no issues.
Diagnostically, these concurrent blood clots, with history of
prior thrombophlebitis in ___, are concerning for a
hypercoagulable state. The differential includes
inherited/sporadic thrombophilia and malignancy.
Antiphospholipid testing (cardiolipin Abs, beta-2-glycoprotein
Abs, lupus anticoagulant) was negative. We deferred rest of
thrombophilia workup to outpatient setting once clots resolve.
In regards to malignancy, she had no evidence on CT
chest-abdomen-pelvis, but could still ___ a cancer somewhere,
such as the colon. She stated she is up to date on mammograms
but not colon cancer screening or pap testing. Of note, she has
had 10-pound weight loss since ___ and complains of
decreased appetite. There is a family H/O gastric cancer in her
mother. She was discharged on dabigtran 150 mg BID, a new
medication.
# Acute HFrEF. Previously normal LVEF (___), now with LVEF
20% on TTE ___, with elevated pro-BNP but normal troponin-T.
The etiology was not entirely clear. Distribution of
hypo-/akinesis somewhat consistent with Takotsubo; could be
tachycardia-induced cardiomyopathy from atrial fibrillation with
RVR. Alternatively, viral cardiomyopathy (given recent URI)
might have triggered new atrial fibrillation. Cardimyopathy
likely non-ischemic given reportedly normal coronary angiography
___. She had mild volume overload on exam with shortness of
breath and received intermittent diuresis with furosemide
boluses with good effect for her diastolic heart failure. She
was also started on captopril, later switched to lisinopril 5mg,
for afterload reduction given reduced EF, though this was
discontinued on day of discharge due to hyperkalemia to 5.6. She
was discharged home on furosemide 60mg PO daily, a new
medication, as well as diltiazem, digoxin, and metoprolol
succinate as above.
# Hyperkalemia: Patient had potassium of 5.6 on ___, repeat
whole blood sample was normal at 4.2. Chemistry ___ again
showed hyperkalemia to 5.5, repeat whole blood sample was 4.9.
This is most likely secondary to ACE-inhibition and so
lisinopril was discontinued. BUN/Cr within normal limits
therefore not due to renal insufficiency, also no signs/symptoms
of digoxin toxicity and on a very low dose so dig toxicity
highly unlikely. Potassium should be monitored as an outpatient,
please check this value at PCP follow up on ___.
# Chest pain: On admission, patient presented with atypical,
nonexertional pain, with chest wall tender to palpation, and was
diagnosed with musculoskeletal pain. Troponin-T and CK-MB were
negative in the ED and again on ___ and ___, and EKG showed no
acute ST changes. History of coronary angiography in ___
with reportedly no CAD. Therefore pain felt to be most likely
musculoskeletal, secondary to coughing given persistent URI. She
was given acetaminophen and lidocaine patches as needed with
good effect. If chest pain persists as outpatient, cardiology
can consider outpatient stress testing.
# E. coli uncomplicated UTI: She spiked a fever to 102.2 on ___
and had UA with WBCs and +nitrites and urine culture growing E
coli. She was asymptomatic, with no dysuria or flank pain.
However, given her persistent atrial fibrillation with RVR, with
cardioversion not an option, it was felt to be reasonable to
treat a potential infectious source to limit any ongoing
triggers for her AF and decrease her cardiovascular demand. She
was initially started on IV ceftriaxone and then switched to
Bactrim given pan-sensitive E. coli for a total 3-day course and
remained afebrile and asymptomatic.
# Hypertension: Patient has history of hypertension, on
amlodipine and metoprolol at home. Amlodipine was stopped
because of diltiazem use for synergy in rate control. Captopril
was added for LVSD. She was discharged home on metoprolol
succinate 200 mg daily as above (up from 100 mg on admission),
diltiazem and captopril.
TRANSITIONAL ISSUES
[ ] Hyperkalemia on day of discharge (5.5) and day prior (5.6),
so lisinopril discontinued. Please recheck K at PCP follow up on
___ to ensure normal value.
[ ] Consider completing hypercoagulability workup: Protein C/S
deficiency, factor V leiden, antithrombin deficiency,
prothrombin gene mutation testing. For malignancy workup:
colonoscopy, pap testing, mammogram.
[ ] Dr. ___ office to arrange cardiology follow up
[ ] New medications: Furosemide 60 mg daily, digoxin 0.125 mg
q2d, dabigatran 150 mg bid, diltiazem ER mg 120 daily
[ ] Changed meds: Metoprolol succinate 200 mg daily (from 100 mg
daily)
[ ] Discontinued meds: amlodipine
[ ] Discharge weight: 59.2 kg
[ ] Discharge Cr: 0.7
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sensation of movement in head
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of CNS lymphoma (dx ___, recurred ___,
composite Hodgkin's and non-Hodkin's lymphoma dx in ___ s/p
ABVD, rituximab, and mBACOD presented to the ED with
"dizziness", which is his name for the sensation that a very
very mild pain is moving around in his head. He denies actual
dizziness. Had similar symptoms before attributed to flare of
CNS lymphoma. He denies any sensation of the room spinning or of
lightheadedness/feeling like he's going to pass out. He has had
vertigo before and says this feels different. He has had this
dizzy feeling for four days. It was insidious in onset and has
been constant. He says he may feel somewhat off balance but
denies overet disequilibrium, loss of consciousness, or falls.
He did have a fall a month ago where he tripped and caught
himself but cut his nose. He denies head trauma. The patient has
also had significant stress this week after his brother died.
He has also had a recurrence of his floaters, R>L. He has had
floaters associated with his lymphoma that improve after chemo
but always recur.
Last chemo ___ (methotrexate). His next chemo will be ___.
In the ED, initial VS were: 98.2 66 144/96 18 99%
Labs were notable for: Abs lymph 0.80
Imaging included: Head CT: No acute intracranial process.
Consults called: ___- covering MD ___ admission
for MRI to rule out worsneing lymphoma.
Recommendations: Admit to omed
Treatments received: 1000 mL NS
EKG: NSR. QTc 403.
REVIEW OF SYSTEMS:
The pt denies HA, SOB, N/V, F/C, SOB, chest pain, palpitations,
stomach pain, change in bowel movements, problems with
urination, weakness, or numbness.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: hadnon-specific constitutional symptoms: fevers and 4
month history of non-productive cough. PET scan revealed FDG
avid
lymph nodes
- ___: Underwent cervical mediastinoscopy. Pathology
consistent with composite lymphoma (Hodgkin's and non-Hodgkin's
lymphoma). Underwent 1 cycle of ABVD and 6 cycles of rituximab
and mBACOD. Had complete systemic response.
- ___: Began seeing floaters in his eyes. Seen at
___ and thought to have
lymphomatous involvement of vitreous. Later, he began dropping
things from his right hand from weakness, and was having
problems
with his hand writing.
- ___: Presented to ___ ER. CT scan revealed left frontal
mass with surrounding edema. He was transferred to the
Neurosurgery Service and underwent a stereotactic brain biopsy
on
___ and the pathology was consistent with lymphoma.
- s/p 5 induction cycles of high-dose methotrexate at 6
grams/m2,
and had a complete response.
- completed 19 maintenance doses of high-dose methotrexate at 6
gram/m2; the last 11 were given together with rituximab. Most
recent was ___. He had a complete response.
- ___ developed ataxia, MRI suspicious for CNS lymphoma
recurrence. no evidence of systemic lymphoma on workup, started
high dose methotrexate reinduction at 8g/m2 with Rituxan ___, completed
- ___ maintenance rituxan and HD MTX started on ___
- ___ c19 rituxin
- ___ C2 maintenance hd mtx admission
- ___ c21 rituxan
- ___ C3 maintenance HD MTX
- ___ C21 rituxan
- ___ C8 maintenace mtx
- ___ c22 rituxin
- ___ C9 maintenance MTX
- ___ C23 rituxan
- ___ C10 maintenance HD MTX
PAST MEDICAL HISTORY:
- Renal tuberculosis diagnosed in ___ and treated with
rifampin,isoniazid and ethambutol for ___ years
- hyperlipidemia
- vertigo
- GERD
Social History:
___
Family History:
His father had coronary artery disease. His 2 brothers also have
coronary artery disease. One brother passed away in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 140/80 61 18 97%RA
GENERAL: Pleasant, NAD
HEENT: NC/AT, EOMI, no nystagmus, PERRL, MMM. No thrush. No
cervical LAD. No carotid bruits.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: soft, NT/ND, no rebound or guarding. No HSM.
EXT: No lower extremity pitting edema
NEURO: A&O x 3, Face symmetric, tongue midline, senesation
intact. ___ strength & light touch sensation intact in upper and
lower extermities b/l. No dysdiadochokinesia to rapid
alternating movement, finger to nose, heel to shin.
SKIN: Warm and dry, without rashes
DISCHARGE PHYSICAL EXAM:
VS: 97.4 120/88 69 16 98%RA
GENERAL: Pleasant, NAD
HEENT: NC/AT
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: soft, NT/ND, no rebound or guarding. No HSM.
EXT: No lower extremity pitting edema
NEURO: A&O x 3, Face symmetric.
SKIN: Warm and dry, without rashes
Pertinent Results:
ADMISSION LABS:
___ 08:00AM BLOOD WBC-5.0 RBC-4.75 Hgb-14.2 Hct-41.5 MCV-87
MCH-29.9 MCHC-34.2 RDW-12.6 RDWSD-40.1 Plt ___
___ 08:00AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-14
___ 08:00AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
DISCHARGE LABS:
___ 06:33AM BLOOD WBC-4.8 RBC-4.66 Hgb-14.2 Hct-40.3 MCV-87
MCH-30.5 MCHC-35.2 RDW-12.5 RDWSD-39.2 Plt ___
___ 06:33AM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-26 AnGap-13
___ 06:33AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
IMAGING:
Head CT ___:
IMPRESSION:
1. No acute intracranial hemorrhage or new mass effect.
2. Hypodensity within the posterior limb of the left internal
capsule extending into the left cerebral peduncle appears
similar to the signal abnormalities seen on prior MRI and are
better assessed on that modality. No new gross lesions are
identified on this CT exam, but MRI with contrast is a more
sensitive study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Magnesium Citrate 300 mL PO DAILY:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Fluconazole 100 mg PO Q24H
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluconazole 100 mg PO Q24H
4. Magnesium Citrate 300 mL PO DAILY:PRN constipation
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
1. CNS lymphoma
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: ___ with dizziness, history of CNS lymphoma // Eval for bleed
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head ___
FINDINGS:
There is no evidence of acute territorial infarction or hemorrhage. Left
posterior limb of the internal capsule hypodensity extending into the left
cerebral peduncle is again noted, and corresponds to the abnormalities seen on
FLAIR sequence on recent MRI. Focal white matter hypodensity in the left
frontal centrum semiovale (02:22) is nonspecific, but may be due to chronic
small vessel ischemic disease. Mild prominence of the ventricles and sulci is
suggestive of age-appropriate involutional changes.
Left frontal burr hole is again seen. Mucosal thickening in the left
maxillary sinus is minimal. There is mild mucosal thickening in the ethmoid
air cells, sphenoid sinuses, and left frontoethmoidal recess. The mastoid air
cells and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage or new mass effect.
2. Hypodensity within the posterior limb of the left internal capsule
extending into the left cerebral peduncle appears similar to the signal
abnormalities seen on prior MRI and are better assessed on that modality. No
new gross lesions are identified on this CT exam, but MRI with contrast is a
more sensitive study.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ w/ CNS lymphoma (dx ___, recurred ___ as well as h/o
composite Hodgkin's and non-Hodkin's lymphoma dx in ___ s/p ABVD, rituximab,
and mBACOD w/ complete systemic response who developed CNS-only relapse now in
remission after starting reinduction HDMTX who presents with a sensation of
something moving in his head. // Evaluate for progression of his CNS
lymphoma.
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: Head CT ___ and brain MR ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or recent infarction. Again seen are areas of white matter hyperintensity on
FLAIR that most likely represent chronic small vessel ischemia. A tract of
hyperintensity extending into the left cerebral peduncle may reflect Wallerian
degeneration. The ventricles and sulci are prominent in an atrophic pattern.
There is no abnormal enhancement after contrast administration.
IMPRESSION:
1. No change since ___. White matter changes likely reflecting
chronic ischemia. No evidence of hemorrhage or recent infarction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.3
heartrate: 67.0
resprate: 16.0
o2sat: 100.0
sbp: 156.0
dbp: 101.0
level of pain: 0
level of acuity: 3.0 | ___ with CNS lymphoma (dx ___, recurred ___ as well as h/o
composite Hodgkin's and non-Hodkin's lymphoma dx in ___ s/p
ABVD, rituximab, and mBACOD w/ complete systemic response who
developed CNS-only relapse (now in remission after starting
reinduction HDMTX) presented with a sensation of something
moving in his head.
#Head sensation: Pt came in because he is going to ___ on ___
and wanted to make sure nothing serious is going on. He has had
this feeling previously, attributed to CNS lymphoma, but it got
better with chemo. His current symptoms may now be an acute
stress reaction given his brother's recent death 2 weeks ago. He
denies dizziness, lightheadedness, vertigo, loss of
conciousness/falls, trauma. No focal neuro deficits. CT head was
negative for acute process. MRI showed no new mass or change
since ___.
#Floaters: Pt has had chronic floaters that always recur ___ mo
after every chemo. No flashes/darkness/pain. He has follow-up
with retina specialist.
#Candidiasis: Pt had 4 doses fluconazole left on admission,
including night of ___. He was continued on this medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa(Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
ORIF of left pelvic fracture with screw placement (orthopedics,
___
History of Present Illness:
___ yo Female who lives with her family who got up to use
bathroom
and fell directly onto her left side. She subsequently was
unable to ambulate afterward. Her family was concerned and
brought her to the ed because felt like her left leg was hurting
her. She has some severe dementia and can be combatative and is
not able to truly have a conversation according to her daughter.
She subsequently thus is only known to have pain with the left
leg. She does have a walker at home and is ambulatory without
it.
Past Medical History:
HTN, COPD, Dementia, prior falls
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
Temp: 97.3 HR: 108 BP: 116/65 Resp: 18 O(2)Sat: 96 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: mae, nvi
Psych: demented
___: No petechiae
DISCHARGE EXAM
VS Tc 97.9 Tm 97.9 118/78 87 (77-87) 22 96-97% RA
GEN awake, alert, elderly woman resting comfortably in bed, not
responding to questions
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM good air entry anteriorly, no wheezes/rhonchi/crackles,
unable
to examine posteriorly due to patient cooperation
CV irregular, normal S1/S2, no m/r/g appreciated
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, left hip dressing c/d/i
NEURO CNs2-12 unable to be tested, moves all 4 extremeties
SKIN no ulcers or lesions noted
Pertinent Results:
ADMISSION LABS
___ 08:45PM HCT-31.2*
___ 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG
___ 03:30AM URINE RBC-1 WBC-40* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-2
___ 03:30AM URINE HYALINE-9*
___ 03:30AM URINE MUCOUS-MOD
___ 03:15AM GLUCOSE-143* UREA N-22* CREAT-0.5 SODIUM-141
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-34* ANION GAP-14
___ 03:15AM WBC-16.7* RBC-4.59 HGB-12.3 HCT-39.1 MCV-85
MCH-26.7* MCHC-31.3 RDW-14.5
___ 03:15AM NEUTS-82.3* LYMPHS-11.5* MONOS-5.9 EOS-0.2
BASOS-0.2
___ 03:15AM PLT COUNT-299
___ 03:15AM ___ PTT-26.9 ___
DISCHARGE LABS
___ 07:10AM BLOOD WBC-20.1* RBC-4.48 Hgb-12.1 Hct-38.5
MCV-86 MCH-27.1 MCHC-31.5 RDW-15.2 Plt ___
___ 07:10AM BLOOD Glucose-101* UreaN-17 Creat-0.4 Na-140
K-4.6 Cl-98 HCO3-34* AnGap-13
PERTINENT RESULTS
___ 08:45PM BLOOD Hct-31.2*
___ 05:28AM BLOOD WBC-13.2* RBC-3.82* Hgb-10.5* Hct-32.9*
MCV-86 MCH-27.6 MCHC-32.0 RDW-14.0 Plt ___
___ 04:31PM BLOOD WBC-12.9* RBC-3.93* Hgb-10.6* Hct-34.6*
MCV-88 MCH-27.0 MCHC-30.7* RDW-14.1 Plt ___
___ 06:55AM BLOOD WBC-21.8*# RBC-4.19* Hgb-11.2* Hct-36.2
MCV-86 MCH-26.7* MCHC-30.9* RDW-14.1 Plt ___
___ 12:41AM BLOOD WBC-19.0* RBC-4.04* Hgb-10.7* Hct-35.2*
MCV-87 MCH-26.4* MCHC-30.3* RDW-14.5 Plt ___
___ 12:10PM BLOOD WBC-18.4* RBC-4.01* Hgb-10.7* Hct-34.6*
MCV-86 MCH-26.6* MCHC-30.8* RDW-14.3 Plt ___
___ 04:26AM BLOOD WBC-20.7* RBC-4.42 Hgb-11.5* Hct-37.0
MCV-84 MCH-26.0* MCHC-31.0 RDW-14.3 Plt ___
___ 12:41AM BLOOD Neuts-80.1* Lymphs-13.1* Monos-6.5
Eos-0.2 Baso-0.1
MICRO
___ 3:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 6:16 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING
PELVIS (AP ONLY) Study Date of ___ 3:45 AM
IMPRESSION: Intra-articular, comminuted left iliac wing fracture
and mildly displaced left pubic rami fractures, better
delineated on prior CT from ___.
CHEST (PORTABLE AP) Study Date of ___ 7:49 AM
IMPRESSION:
1. Extensive right pleural calcifications of unclear etiology.
If prior
imaging is available, a direct comparison can be made.
2. Probable small right pleural effusion.
PELVIS (AP ONLY) PORT Study Date of ___ 3:06 ___
FINDINGS: Two opaque screws are seen transfixing previously
described
fractures of the left iliac wing and pubic ramus. Further
information can be gathered from the operative report.
CHEST (PORTABLE AP) Study Date of ___ 4:17 AM
IMPRESSION: The patient has a calcific right fibrothorax, in
which the lower lung was better aerated on ___ than
subsequently. This suggests difficulty clearing secretions.
There is no pulmonary edema in the recently well aerated left
lung, though there is a small left pleural effusion that
developed since ___ and the left pulmonary artery is
larger. In the appropriate clinical situation, this could be
manifestation of acute pulmonary embolus or alternatively
atypical heart failure. Findings were reported by telephone to
the patient's Nurse ___ at 9:40 a.m.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of ___
3:48 ___
CONCLUSION:
1. There is no pulmonary embolism and no acute aortic syndrome.
2. Right fibrothorax with significant chest wall deformity is
presumed to be from prior tuberculous infection.
3. Left lung is unremarkable. Right lung which is of small
caliber contains mild bronchiectasis with bronchial wall
thickening and impaction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Memantine 10 mg PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth
twice a day Disp #*30 Capsule Refills:*3
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Amiodarone 400 mg PO BID
4. Ciprofloxacin HCl 250 mg PO Q12H Duration: 7 Days
5. Memantine 10 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
please hold for sedation, rr< 10
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q 4 hrs
Disp #*20 Tablet Refills:*0
8. Senna 1 TAB PO DAILY
9. Metoprolol Succinate XL 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hip fracture
Acute Complicated cystitis
Atrial fibrillation with rapid ventricular response
Discharge Condition:
SEVERE DEMENTIA
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
STUDY: Pelvis intraoperative study, ___.
CLINICAL HISTORY: Patient with pelvic fracture ORIF.
FINDINGS: Comparison is made to the prior radiographs eight hours earlier.
Several images of the pelvis from the operating room demonstrate placement of
a lag screw across the left superior pubic rami. There are fractures of the
left superior and inferior pubic rami. There is also a fracture seen in the
iliac bone. This is fixated by a cortical screw. There are no signs for
hardware-related complications. The total intraoperative fluoroscopic time
was 126 seconds. Please refer to the procedure note for additional details.
Radiology Report
HISTORY: Fall and pelvic fracture. Pre-operative evaluation.
COMPARISON: Chest radiograph from ___, ___.
FINDINGS: Frontal chest radiograph is markedly rotated to the right side.
Thoracic scoliosis also limits the study. Extensive pleural calcifications
throughout the right hemithorax are of unknown chronicity. Additionally, a
pleural effusion is likely present on the right, but the size is difficult to
determine due to positioning. The left lung is clear and there is no
pneumothorax. Heart size is not well evaluated due to patient positioning.
Superior subluxation of the right glenohumeral joint is noted.
IMPRESSION:
1. Extensive right pleural calcifications of unclear etiology. If prior
imaging is available, a direct comparison can be made.
2. Probable small right pleural effusion.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: Patient with severe dementia and unable to hold still.
With low-grade fever.
FINDINGS: Comparison is made to prior study from ___.
Study is very limited due to patient's positioning and likely element of
scoliosis. There is increased density projecting over the right lung as well
as there is volume loss and calcification of the pleura on the right side. It
is difficult to exclude pneumothorax based on these images and if there is
high clinical concern for pathology, would recommend a chest CT. The left
lung appears well aerated. Heart size is upper limits of normal. Overall,
allowing for differences in technique and patient's positioning, there is no
appreciable change since the ___ study.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ woman with new onset atrial fibrillation.
Evaluate fluid overload.
FINDINGS: Study is very limited due to volume loss along the right chest as
well as pleural calcifications. Increased density throughout the entire right
lung thus underlying infiltrate or edema would be difficult to exclude. There
is likely a small right pleural effusion. The left lung appears relatively
clear without focal consolidation or definite pulmonary edema. Heart size
demonstrates left ventricular hypertrophy. Overall, these findings appear
relatively stable.
Radiology Report
AP CHEST, 4:57 A.M., ___
HISTORY: ___ woman with concern for fluid overload.
IMPRESSION: The patient has a calcific right fibrothorax, in which the lower
lung was better aerated on ___ than subsequently. This suggests
difficulty clearing secretions. There is no pulmonary edema in the recently
well aerated left lung, though there is a small left pleural effusion that
developed since ___ and the left pulmonary artery is larger. In the
appropriate clinical situation, this could be manifestation of acute pulmonary
embolus or alternatively atypical heart failure. Findings were reported by
telephone to the patient's Nurse ___ at 9:40 a.m.
Radiology Report
HISTORY: Pelvic screw placement.
FINDINGS: Two opaque screws are seen transfixing previously described
fractures of the left iliac wing and pubic ramus. Further information can be
gathered from the operative report.
Radiology Report
CHEST CTA WITH CONTRAST
INDICATION: Patient with intraoperative atrial fibrillation, tachycardia,
shortness of breath, enlarged pulmonary artery on chest x-ray. Evaluate for
pulmonary embolism.
COMPARISON: No prior chest CT. Chest x-ray done yesterday.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with administration of IV contrast following the CTA protocol.
FINDINGS:
The exam is limited due to remodeling of the right hemithorax with volume loss
due to fibrothorax, presumably from prior tuberculous infection.
HEART AND GREAT VESSELS:
There is no pulmonary embolism until segmental level on the left side.
Distally, the exam is nondiagnostic due to multiple breathing artifacts. The
vessels on the right side are small due to the fibrothorax.
Main pulmonary artery is not dilated. The left pulmonary artery is dilated
but this is a compensation for the right side. There is no acute aortic
syndrome. Coronary arteries and the aorta are moderately calcified.
MEDIASTINUM:
Moderate left pleural effusion is nonhemorrhagic. There is no pathologic
supraclavicular, mediastinal or axillary lymph node enlargement by CT size
criteria.
LUNGS AND AIRWAYS:
There is calcified granuloma in both lungs. There is no significant finding
on the left lung. Right lung is smaller due to the fibrothorax. It is
accompanied with mild bronchiectasis with bronchial wall thickening and
impaction.
UPPER ABDOMEN:
This study is not tailored for assessment for intra-abdominal organs. The
upper abdomen appears unremarkable.
OSSEOUS STRUCTURES:
There are multiple deformities of the spine and ribcage.
CONCLUSION:
1. There is no pulmonary embolism and no acute aortic syndrome.
2. Right fibrothorax with significant chest wall deformity is presumed to be
from prior tuberculous infection.
3. Left lung is unremarkable. Right lung which is of small caliber contains
mild bronchiectasis with bronchial wall thickening and impaction.
Radiology Report
HISTORY: Fall with pelvic pain.
COMPARISON: Pelvic radiograph ___ at 11:58pm and CT pelvis ___ at 12:25am from ___.
FINDINGS: A single supine view of the pelvis was obtained. There are mildly
displaced fractures of left superior and inferior pubic rami. Additionally, a
comminuted fracture of the left iliac wing with extension into the left
sacroiliac joint is better delineated on the prior CT scan. There is slight
widening of the left sacroiliac joint. No femoral fracture is identified on
this single view. There is mild degenerative change in the hip joints
bilaterally with loss of joint space and subchondral sclerosis. There is no
pubic symphysis or right sacroiliac joint diastasis. Nonobstructive bowel gas
pattern obscures fine bony detail of the sacrum. Phleboliths are noted in the
pelvis.
IMPRESSION: Intra-articular, comminuted left iliac wing fracture and mildly
displaced left pubic rami fractures, better delineated on prior CT from
___.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: PELVIC FRACTURE
Diagnosed with FRACTURE OF PUBIS-CLOSED, OTHER FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 97.3
heartrate: 108.0
resprate: 18.0
o2sat: 96.0
sbp: 116.0
dbp: 65.0
level of pain: 13
level of acuity: 2.0 | ___ with history of dementia, COPD, arthritis s/p fall w/ hip
fracture. Patient underwent emergent repair of fracture on
___. She was admitted to the surgical ICU-post op from
___. Her post-op course was complicated by two
episodes of atrial fibrillation with RVR which responded to
pharmacological therapy, as well as a UTI (as below).
# Afib with RVR: On post-op day 3, patient developed afib with
RVR with rates in the 170s/180s and blood pressure in the 60-80s
systolic. Patient was treated with IV amiodarone bolus and then
drip, with conversion to sinus rhythmn. Her amiodarone was
converted to 400mg PO TID. She developed a second episode of
afib with RVR on ___ which responded to metoprolol IV. She
was started on metoprolol 25 mg TID with no further episodes of
RVR. She was transferred to the floor in sinus rhythmn and
remained rate controlled on her oral regimen with no further
episodes of RVR. She did have brief episodes of afib that self
resolved, however, without fast ventricular response. Most
likely trigger of her afib was stress of surgery. Patient did
have a CXR after one of her RVR episodes that commented on en
enlarged left pulmonary artery suggestive of possible PE. For
this reason, she underwent CT-A to further evaluate for PE,
which was negative. Medical team discussed risks and benefits
of anticoagulation going forward (CHADS2-VASC score of 3
indicates anticoagulation in this setting) with daughter (HCP)
who expressed preference to pursue anticoagulation. Patient
will be started on dabigatran 150 mg twice a day for stroke
prophylaxis. She will continue on metoprolol and amiodarone.
She should have cardiology follow-up in ___ weeks for further
management of her afib.
# UTI: On post-op day 3 patient grew out enterobacter sensitive
to cipro. Possibly due to foley instrumentation from procedure.
She was started on ciprofloxacin and will complete a course
through ___.
# Left hip fracture: Patient suffered mechanical fall with no
LOC. She underwent repair with ORIF and pin placement on ___.
Post-op course complicated by above. Her pain was well
controlled on oxycodone as needed. She was initially treated
with lovenox for DVT prophylaxis but will be on dabigatran going
forward for atrial fibrillation (see above), so lovenox will be
discontinued. As per orthopedics, she should be weight bearing
as tolerated on her right lower extremity and touch down weight
bearing on her left extremity. She should have follow-up
scheduled with Dr. ___ orthopedic surgery, in 2 weeks
for further management (___).
# Leukocytosis: patient was noted to have white count that was
16 on presentation and remained in the 17's-20s throughout
admission. There was a question of whether this was a chronic
process. It's possible it is also due to the stress of hip
surgery. As per discussion with PCP, ___ count one year ago
was within normal limits. She did have an underlying UTI but no
signs or symptoms of systemic infection. We recommend further
follow-up with PCP to assess resolution and possible workup.
# Dementia: The patient has underlying dementia, and as per
report, is nonverbal and AAOx0. We pursued non pharmacologic
methods to minimize delirium, including orientating to day night
cylce, properly controlling pain, ensuring good BMs, minimizing
tethers.
TRANSITIONAL ISSUES
1. Patient needs to be established with cardiology for new onset
afib, she was started on dabigatran for risk of stroke as well
as metoprolol and amiodarone.
2. As per discussion with patient's daughter (HCP), she remains
DNR/DNI but OK for cardioversion and IV medications for
arrythmias.
3. Patient needs follow-up with orthopedics in 2 weeks (Dr.
___, ___
4. Patient needs monitoring for of leukocytosis and
consideration of workup if persistently elevated outside of the
post-op setting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
open reduction and internal fixation of left acetabular fracture
History of Present Illness:
This is a ___ female who was involved in a high speed MVA
restrained passenger who was transferred from ___.
At scene she was HD stable with a GCS of 15. She was pan scanned
at the OSH and was found to have multiple L rib fxr (___) and L
hip fracture dislocation. She presented to ___ ED on ___. In
the ED, conscious sedation was performed. Closed reduction was
performed and a traction pin was placed. Postreduction films
demonstrated improved alignment.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
A&O x 3
Calm and comfortable
Facial laceration
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearm compartments soft
No pain with passive motion
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDS fire
2+ radial pulses
Elbow stable to varus, valgus, rotatory stresses.
b/l Shoulder TTP at the AC joint, long head of biceps,
subdeltoid bursa
Pelvis stable to AP and lateral compression and painful to
lateral compression
BLE skin clean and intact
Mild tenderness to palpation over left lateral pelvic area, no
deformity, erythema, edema, induration.
Diffuse ecchymosis over lateral aspect of pelvis noted
Thighs and leg compartments soft
No pain with passive motion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ ___ TA Peroneals Fire
1+ ___ and DP pulses
Knee stable to varus and valgus stress.
Negative anterior, posterior drawer signs.
PHYSICAL EXAM UPON DISCHARGE:
Afebrile, HR 102
A&Ox3
Respirations non-labored
LLE: Dressing changed, incision with staples in place, no
drainage/purulence/erythema; ___ strength in ___ ___
Q/HS/IP, pain-limited and improving since surgery. Sensation
intact over foot in ___ distributions. Toes warm and
well-perfused. Dressing in pace, no drainage noted.
Pertinent Results:
___ 01:29PM GLUCOSE-168* UREA N-11 CREAT-0.6 SODIUM-130*
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-10
___ 01:29PM CALCIUM-7.9* MAGNESIUM-1.8
___ 01:29PM WBC-5.4 RBC-3.93* HGB-9.8* HCT-32.5* MCV-83
MCH-25.0* MCHC-30.1* RDW-12.9
___ 01:29PM PLT COUNT-174
___ 09:52PM PO2-38* PCO2-59* PH-7.31* TOTAL CO2-31* BASE
XS-0 COMMENTS-GREEN TOP
___ 09:52PM GLUCOSE-167* LACTATE-1.9 NA+-140 K+-4.4
CL--97
___ 09:52PM HGB-12.7 calcHCT-38 O2 SAT-60 CARBOXYHB-2.0
MET HGB-0.3
___ 09:52PM freeCa-1.16
___ 08:40PM UREA N-14 CREAT-0.6
___ 08:40PM estGFR-Using this
___ 08:40PM LIPASE-25
___ 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:40PM WBC-8.5 RBC-5.00 HGB-12.7 HCT-40.1 MCV-80*
MCH-25.3* MCHC-31.6 RDW-12.7
___ 08:40PM PLT COUNT-206
___ 08:40PM ___ PTT-20.5* ___
___ 08:40PM ___ 07:30AM BLOOD WBC-4.5 RBC-3.19* Hgb-8.1* Hct-25.5*
MCV-80* MCH-25.3* MCHC-31.6 RDW-13.1 Plt ___
___ 08:00AM BLOOD WBC-6.6 RBC-2.98* Hgb-7.6* Hct-24.0*
MCV-80* MCH-25.4* MCHC-31.6 RDW-13.1 Plt ___
___ 08:15AM BLOOD WBC-6.4 RBC-3.52* Hgb-9.3* Hct-29.5*
MCV-84 MCH-26.3* MCHC-31.4 RDW-14.7 Plt ___
Imaging: CT imaging demonstrates a fracture dislocation of the L
hip with involvement of the posterior wall.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl ___AILY:PRN constipation
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Enoxaparin Sodium 40 mg SC QPM Duration: 9 Days Start:
___, First Dose: Next Routine Administration Time
Continue for 9 day following discharge
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
do not drink alcohol or drive while taking
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours
Disp #*45 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD DAILY Disp #*45 Tablet
Refills:*0
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch over rib
fractures (left chest) once daily Disp #*7 Unit Refills:*0
7. Senna 2 TAB PO BID:PRN constipation
8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
Continue for 3 days (started morning of ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left acetabular fracture
multiple left-sided rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Hip pain status post reduction. Assess reduction.
COMPARISON: CT from 40 minutes prior.
FINDINGS:
Frontal and Judet views were obtained of the pelvis. Fracture extending
through the left inferior pubic ramus, ischial tuberosity and posterior
acetabulum is re- demonstrated with persistent mild lateral displacement. The
femoral head has been reduced and now is seated within the acetabulum with a
bony fragment projecting between the femoral head and the superior rim of the
acetabulum measuring approximately 2 cm. It is uncertain on these images, if
this fragment is within the joint space or deep to the joint; however given
the distribution of fracture fragments and likely course of the femoral head
reduction it is possible that this was trapped between the acetabulum and
femoral head during reduction.
Radiology Report
INDICATION: Status post hip reduction, assess.
TECHNIQUE: Axial MDCT images were acquired through the pelvis without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
COMPARISON: CT pelvis, ___.
FINDINGS:
There has been interval reduction of the left hip dislocation with anatomic
alignment. There are at least two large free fragments within the joint
space, measuring 12 x 11 x 16 mm (2:64) and 13 x 6 x 13 mm. A vertically
oriented comminuted fracture involves the posterior column of the acetabulum.
Small amounts of air are noted within the joint space (2:73). Enlargement of
the muscles around the left hip joint, particularly the obturator internus and
piriformis are consistent with hematoma formation. A small amount of hematoma
is again noted along the left pelvic sidewall.
The uterus is enlarged and lobulated in contour, most consistent with fibroids
however the uterus is incompletely assessed on this non-contrast CT. Air
again noted in the bladder, a Foley catheter is in situ. Visualized portions
of the large bowel are unremarkable. Stranding of the subcutaneous tissues
overlying the iliac spine is presumed to be trauma related.
IMPRESSION:
1. Adequate reduction of the left hip dislocation.
2. Comminuted posterior column fracture of the acetabulum with two large
intra-articular loose bodies.
3. Hemarthrosis.
4. Enlarged pelvic girdle musculature is consistent with hematoma formation.
5. Hematoma about the left pelvic sidewall presumably secondary to fracture.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show placement of a complex
fixation device about left acetabular fracture. Further information can be
gathered from the operative report.
Radiology Report
HISTORY: Status post motor vehicle collision. Outside hospital study
submitted for second opinion read.
TECHNIQUE: The outside hospital study was performed with axial images through
the brain. This exam is somewhat limited by streak artifact.
COMPARISON: None available.
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
are patent and there is preservation of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
Somewhat limited study due to streak artifact, but no obvious acute
intracranial abnormality.
Radiology Report
INDICATION: Left acetabular ORIF.
COMPARISON: ___.
ONE VIEW PELVIS
Malleable plate and screw fixation of the comminuted acetabular fracture
extending into the left inferior pubic ramus and ischium. There is a
displaced 17 mm osseous fragment laterally. Soft tissue swelling and skin
staples are noted.
Radiology Report
HISTORY: Femoral traction pin, assess placement.
COMPARISON: ___ radiographs ___.
FINDINGS:
2 views were obtained of the left knee. The femoral traction pin has been
placed in the distal femoral metadiaphysis. No fracture or dislocation is
seen.
Radiology Report
INDICATION: Hip pain, evaluate acetabular fracture for preoperative planning.
TECHNIQUE: Axial MDCT images were acquired through the pelvis without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
COMPARISON: Trauma series ___.
FINDINGS:
There is a posterior superior hip dislocation on the left side with a
vertically oriented comminuted fracture through the posterior column of the
acetabulum and free fragments seen (2:65). There is a high attenuation joint
effusion (2:71), consistent with a hemarthrosis. A small amount of air is
identified anteriorly within the joint space (2:70).
The acetabular fracture extends into the inferior pubic ramus (400B:89) and
ischial tuberosity. At least two free fragments are identified within the
joint space (400B:81). In addition, there is a subchondral depression along
the superior lateral femoral head (400B:87), consistent with an impaction
fracture. No femoral neck fractures are identified.
On review of soft tissue windows there is enlargement of all muscles of the
pelvic girdle consistent with hematoma formation. The obdurator internus
muscle is enlarged (3:78). There is a small amount of presacral edema (3:70)
and hematoma tracking along the left pelvic sidewall. No additional fractures
are seen. Mild vascular calcification noted. The uterus is enlarged and
irregular in contour, most likely consistent with fibroids; however, this is
incompletely assessed on this non-contrast CT. No free fluid is seen in the
pelvis. Large volume of air in the bladder, urinary catheter in situ.
IMPRESSION:
1. Posterior superior hip dislocation with a comminuted fracture of the
posterior column of the acetabulum.
2. There are at least two free fragments in the joint space.
3. Hemarthrosis in the left hip.
4. Enlargement of the left piriformis and obturator internus muscle,
consistent with hematoma formation. Hematoma tracking along the left pelvic
sidewall presumably from the acetabular fracture.
5. Enlarged uterus most likely due to fibroids, but incompletely assessed on
this study.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with JOINT PAIN-PELVIS, ABDOMINAL PAIN OTHER SPECIED, MV COLLISION NOS-PASNGR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | As noted above, the patient underwent sedation and closed
reduction of dislocated left hip in the ED. The patient was
admitted on ___ to the Acute Care Surgery service for
management of acetabular and rib fractures. The patient
underwent ORIF of left acetabular fracture on ___, performed by
Dr. ___. This was well-tolerated, and the patient was
transferred to the Ortho Trauma service on POD1.
Neuro: Upon admission, pain was controlled primarily with IV
dilaudid.
C-spine was cleared by ACS radiologically, on the basis of OSH
CT scans, which were re-read by ___ radiologists. The patient
did complain of intermittent neck soreness following clearance,
but no neurologic changes in her upper or lower extremities.
Postoperatively, pain was initially controlled with IV dilaudid,
transitiond to PO dilaudid with good effect. She may also
continue to use lidocaine patches for left-sided rib fracture
pain.
CV: The patient was noted on POD1-2 to be hypertensive and
tachycardic, with systolics in the 150s-160s and tachycardia in
the 120s. Hypertension resolved without intervention by POD3.
Additionally, the tachycardia responded to transfusion of 2u
PRBC on POD3 for crit to 24.7 with appropriate post-transfusion
hematocrit response. Her hematocrit subsequently remained stable
and subsequently heart rate was stable in the low 100s.
Throughout stay, patient denied chest pain (aside from localized
musculoskeletal pain associated with rib fractures),
palpitations, or shortness of breath.
Pulm: The patient maintained good oxygenation saturation
throughout her hospitalization, with no oxygen requirement prior
to discharge. Left-sided rib fracture pain was treated with
lidocaine patch as well as systemic narcotics to avoid
splinting; IS use was encouraged.
GI: Pre- and post-operatively, the patient tolerated a regular
diet. She received an appropriate bowel regimen.
ID: Received perioperative ancef.
Heme: Received subq heparin preoperatively and subq lovenox
postoperatively; she will complete a 14 day course of lovenox.
GU: On POD5, the patient complained of hesistancy and discomfort
with urination, and her nurse reported foul-smelling urine.
Urinalysis was notable for + leuks. She was therefore started on
a 3-day course of Bactrim on ___, with urine cultures pending.
Activity: Patient was seen by ___, with recommendations for
discharge to rehab.
On day of discharge, POD 5, the patient was afebrile with stable
vital signs. She will be discharged to rehab. She will complete
a 14 day course of subq lovenox. She will be touch-down weight
bearing with posterior hip dislocation precautions on the left
lower extremity. She will follow-up in ___ trauma clinic in
___ days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Pericardial window for pericardial effusion.
___: Bentall procedure with a mechanical
composite valve conduit, ___ 27 mm valve and
ascending aortic replacement with a 32 mm Gelweave tube
graft.
History of Present Illness:
Mr. ___ is s/p Bentall/mechanical AVR
from ___ with Dr. ___. He returns to the ED from an outside
hospital with chest pain overnight, arm heaviness, and headache.
A head CT at the OSH is negative for acute bleeding. A bedside
echo revealed a moderate pericardial effusion. Tamponade could
not be ruled in or out due to poor windows. He is
hemodynamically
stable and chest pain free on presentation to the ED. His
sternal
incision is healing well. A tremor is noted in his arms, which
his wife states is new.
Past Medical History:
Ascending Aortic Aneurysm
Bicuspid Aortic Valve
Diabetes Mellitus, Type II
Elevated PSA
Gastroesophageal Reflux Disease
Hearing Loss
Migraines
Sleep Apnea, on CPAP
Social History:
___
Family History:
No history of premature CAD or aneurysms.
Physical Exam:
Pulse:88SR Resp: 16 O2 sat:95%RA
B/P ___
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Neuro: bilateral slight arm tremor
Arms/hands with good strength bilaterally
Discharge Exam:
Vital signs: Tmax 98.8, HR 99, SBP 104/68, resp 16, RA 98%
Neuro: intact, A&O x 3
Lungs: diminished bases, regular rate, unlabored
CV: + click, s1 s1, no JVD
abd: soft, +BS, non distended
Ext: warm, trace generalized edema
Wounds: CDI
Pertinent Results:
___ 03:52AM BLOOD WBC-11.7* RBC-3.07* Hgb-9.2* Hct-28.7*
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.0 RDWSD-43.9 Plt ___
___ 03:52AM BLOOD ___ PTT-25.4 ___
___ 02:04AM BLOOD Plt ___
___ 03:52AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-136
K-4.3 Cl-98 HCO3-25 AnGap-13
___ 03:52AM BLOOD Phos-2.4* Mg-2.0
___ TEE
Pre-drainage:
There is a large effusion around the heart, predominantly the
anterolatertal and posterolateral part but partially posterior
to the RV as well. Given the distorted anatomy it is difficult
to adequately assess for obvious signs of left atrial collapse.
The RA and RV are not showing signs of collapse. The ascending
aortic tube graft is noted and integrity is intake. A
bioprosthetic aortic valve is also noted without aortic
insufficiency.
Post drainage:
Pericardial effusion no longer noted at the anterior,
anterolateral and lateral portions of the heart. There is a
trace effusion behind the right heart. Normal function, EF
60-65%.
___ PA&lat
Mediastinal wires and valvular replacement are unchanged. There
is unchanged
extensive cardiomegaly. There is a left retrocardiac opacity
and small
left-sided pleural effusion. There are no pneumothoraces.
Medications on Admission:
ASA 81mg daily, metoprolol tartrate 100 mg TID, Phenytoin Sodium
Extended 800 mg PO QHS, Coumadin 2mg daily for INR goal of ___,
MetFORMIN XR 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO QID:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID Duration: 14 Days
RX *docusate sodium [Stool Softener] 100 mg 1 capsule(s) by
mouth twice a day Disp #*60 Capsule Refills:*0
3. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
4. Milk of Magnesia 30 mL PO DAILY Duration: 2 Weeks
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY Duration: 2 Weeks
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*14 Packet Refills:*0
7. MetFORMIN (Glucophage) 250 mg PO BID
RX *metformin 500 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
8. Metoprolol Tartrate 12.5 mg PO TID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*1
9. Aspirin EC 81 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
tamponade/pericardial effusion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: +1 generalized
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p pericardial window. Please ___
at ___ with abnormalities.// r/o ptx/effusion Contact name: ___,
___: ___
IMPRESSION:
In comparison with the study of ___, following procedure there is a left
chest tube in place with no evidence of pneumothorax. Globular enlargement of
the cardiac silhouette appears stable, as does the retrocardiac opacification
with poor definition of the hemidiaphragm consistent with pleural effusion and
volume loss in left lower lobe. There is subcutaneous gas along the lateral
chest wall on the left and there may be a small pneumopericardium or
mediastinum.
Radiology Report
INDICATION: ___ year old man s/p CT removal// eval for effusion/pneumo
COMPARISON: Radiographs from ___
IMPRESSION:
The left-sided chest tube has been removed. No definite pneumothoraces are
seen. Heart size and mediastinum are prominent. There remains a left
retrocardiac opacity and left-sided pleural effusion. There is subcutaneous
emphysema along the left lower chest wall.
Radiology Report
INDICATION: ___ year old man s/p bentall and pericardial fluid drainage//
predischarge eval, follow up effusions/?pneumothorax
COMPARISON: ___
IMPRESSION:
Mediastinal wires and valvular replacement are unchanged. There is unchanged
extensive cardiomegaly. There is a left retrocardiac opacity and small
left-sided pleural effusion. There are no pneumothoraces.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Pericardial effusion (noninflammatory), Headache
temperature: 96.6
heartrate: 88.0
resprate: 16.0
o2sat: 95.0
sbp: 128.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Patient was brought to the OR on ___ and underwent
pericardial window and removal of large pericardial effusion.
Post procedure he was brought back to the CVICU, he extubated
without difficulty, remained hemodynamically stable. Tachycardic
at times, Lopressor increased, but limited by lower but stable
BP. He was not resumed on diuretic, due to marginal BP. Weaned
off oxygen without difficulty. He was resumed on Coumadin for
his mechanical AVR. Patient was also seen by the neurology
department and on light of his recent seizure activity post
initial heart surgery and subtherapeutic Dilantin. He was
switched to keppra and remained seizure free and neurologically
intact throughout this hospital course. Patient will need to
f/u with neurology as a outpatient, appointment to be arranged-
neurology office will call patient. He continued to progress
well and was deemed safe for discharge to home on POD2. Will
follow up in clinic next week with Dr. ___ repeat PA&lat
to be obtained at that time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / spironolactone / atorvastatin
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___: EGD
History of Present Illness:
Ms ___ is a ___ y/o F with PMH significant for
hepaticojejunostomy ___, due to bile duct leak after
cholecystectomy), cirrhosis ___ EtOH), who presented to outside
hospital for hematemesis, transferred to ___ for further care
for upper GI bleed.
She reports having occasional episodes of hematemesis for the
past year. In the last 24 hours, she notes multiple episodes of
emesis, which were dark. She denies any hematochezia or melena.
Along with this, she also notes diffuse epigastric abdominal
pain. At ___, she was given a Protonix drip and
ceftriaxone given concern for upper GI bleed. She was then
transferred to
___ ED.
The patient reports multiple hospitalizations over the last year
(most recently at ___, but she is unable to provide
further details.
At ___, she did not have any episodes of hematemesis. She did
however have an acute drop of hgb from 12 to 9.7, so she
received 1 u PRBC in the ED. She was also started on octreotide
and admitted to the MICU.
In the ED,
- Initial vitals were: 98.9 84 123/77 18 97% RA
- Labs notable for: Normal H/H, Tbili 2.9
- Imaging was notable for:
US Abd
1. Small volume ascites.
2. Patent main portal vein.
CXR
Small left pleural effusion is new. Superimposed pneumonia
cannot
be excluded.
- Patient was given:
___ 22:14 IV Pantoprazole 40 mg
___ 23:41 IVF NS 1000 mL
Upon arrival to the floor, patient reports that she is having
ongoing diffuse abdominal discomfort. She is frustrated by this
pain.
Past Medical History:
- Cirrhosis
- Hx of alcohol abuse
- CAD, s/p stent in ___
- depression and anxiety
- HTN
- HLD
- Chronic low back pain
PAST SURGICAL HISTORY:
- Whipple procedure for complications from a cholecystectomy,
___
- Status post cholecystectomy in ___, complicated by bile leak.
Social History:
___
Family History:
- Noncontributory to patient's presenting complaint
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Alert, NAD
HEENT: PERRL, EOMI, MMM, mild scleral icterus, poor dentition
CARDIAC: RRR, nl s1,s2, III/VI SEM
PULMONARY: CTAB
ABDOMEN: Mild diffuse epigastric tenderness without guarding. No
HSM. Scars noted in RUQ.
EXTREMITIES: Trace ___ edema, 2+ pulses bilaterally, wwp
SKIN: No rashes
NEURO: AOx3
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 98.2 | 102/71 | 94 | 18 | 94%Ra
GENERAL: Alert, nontoxic, eating breakfast and sitting at the
edge of her bed/
CARDIAC: RRR, nl s1,s2, III/VI SEM heard at all fields
PULMONARY: CTAB without adventitious sounds.
ABDOMEN: no tenderness. No HSM. Scars noted in RUQ.
EXTREMITIES: Trace ___ edema, 2+ pulses bilaterally, wwp
SKIN: No rashes
NEURO: AOx3. No asterixis.
PSYCH: Pleasant, appropriate.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-6.9 RBC-3.94 Hgb-12.3 Hct-37.8 MCV-96
MCH-31.2 MCHC-32.5 RDW-16.8* RDWSD-59.6* Plt Ct-78*
___ 09:30PM BLOOD Neuts-89.0* Lymphs-5.2* Monos-5.2
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.12* AbsLymp-0.36*
AbsMono-0.36 AbsEos-0.01* AbsBaso-0.01
___ 09:56PM BLOOD ___ PTT-34.1 ___
___ 09:30PM BLOOD Glucose-146* UreaN-7 Creat-1.0 Na-144
K-4.1 Cl-98 HCO3-30 AnGap-16
___ 09:30PM BLOOD ALT-14 AST-48* AlkPhos-119* TotBili-2.9*
___ 09:30PM BLOOD Albumin-2.6*
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:41PM BLOOD Lactate-4.2* K-3.4
IMAGING/STUDIES:
================
CXR ___:
Small left pleural effusion is new. Superimposed pneumonia
cannot be
excluded.
LIVER US ___:
1. Small volume ascites.
2. Patent main portal vein.
MICRO:
=================
___ 3:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
URINE
=================
___ 03:30AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:30AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 03:30AM URINE RBC-24* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-3
___ 03:30AM URINE CastHy-10*
___ 03:30AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 03:30AM URINE UCG-NEGATIVE
DISCHARGE LABS
===============
___ 06:30AM BLOOD WBC-4.8 RBC-3.16* Hgb-9.6* Hct-30.6*
MCV-97 MCH-30.4 MCHC-31.4* RDW-16.1* RDWSD-57.0* Plt Ct-66*
___ 06:30AM BLOOD ___ PTT-35.2 ___
___ 06:30AM BLOOD Glucose-89 UreaN-3* Creat-0.8 Na-138
K-3.2* Cl-99 HCO3-32 AnGap-7*
___ 06:30AM BLOOD ALT-9 AST-24 AlkPhos-124* TotBili-1.0
___ 06:30AM BLOOD Albumin-1.9* Calcium-7.4* Phos-2.7
Mg-1.4*
PERTINENT INTERVAL LABS
==========================
___ 01:50PM BLOOD calTIBC-98* TRF-75*
___ 01:50PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 01:50PM BLOOD ___
___ 01:50PM BLOOD HIV Ab-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID pain
2. DULoxetine 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
5. Nicotine Patch 21 mg/day TD DAILY
6. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
7. Alendronate Sodium 70 mg PO QMON
8. Rifaximin 550 mg PO BID
9. Midodrine 10 mg PO BID
10. Pantoprazole 40 mg PO Q24H
11. magnesium oxide 400 mg oral unknown
12. Lactulose 15 mL PO DAILY BM
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Estradiol 0.5 mg PO DAILY
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
16. melatonin 3 mg oral QHS
17. Metoclopramide 5 mg PO BID:PRN nausea
18. Ondansetron ODT 8 mg PO BID:PRN Nausea/Vomiting - First Line
19. Potassium Chloride 40 mEq PO DAILY
20. Simethicone 80 mg PO Q6H:PRN abdominal pain
21. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
2. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 mL by mouth four times a day Disp
#*1 Bottle Refills:*3
3. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
4. DULoxetine 20 mg PO DAILY
5. Estradiol 0.5 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 600 mg PO TID pain
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
9. Lactulose 15 mL PO DAILY BM
10. Magnesium Oxide 400 mg oral Frequency is Unknown
11. melatonin 3 mg oral QHS
12. Metoclopramide 5 mg PO BID:PRN nausea
13. Midodrine 10 mg PO BID
14. Nicotine Patch 21 mg/day TD DAILY
15. Ondansetron ODT 8 mg PO BID:PRN Nausea/Vomiting - First
Line
16. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain -
Moderate
17. Potassium Chloride 40 mEq PO DAILY
Hold for K >
18. Rifaximin 550 mg PO BID
19. Simethicone 80 mg PO Q6H:PRN abdominal pain
20. Spironolactone 25 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (___)
22. HELD- Alendronate Sodium 70 mg PO QMON This medication was
held. Do not restart Alendronate Sodium until discussion with
primary care
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Severe esophagitis
-Cirrhosis with portal hypertension and small volume ascites
-Roux-en-Y hepaticojejunostomy after bile duct injury from CCY
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 epigastric pain// PNA
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
There has been interval development of a small left pleural effusion, a
superimposed pneumonia cannot be excluded on the basis of this study. Lungs
are otherwise clear without evidence of pulmonary edema or pneumothorax.
Cardiomediastinal silhouette is unchanged and unremarkable. Visualized
osseous structures are unremarkable.
IMPRESSION:
Small left pleural effusion is new. Superimposed pneumonia cannot be
excluded.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ with cirrhosis and UGIB. Evaluate for ascites.
TECHNIQUE: Grayscale ultrasound images were obtained of the 4 quadrants of
the abdomen.
COMPARISON: None.
FINDINGS:
Targeted grayscale ultrasound images were obtained of the 4 quadrants of the
abdomen, revealing small volume ascites. The main portal vein is patent.
IMPRESSION:
1. Small volume ascites.
2. Patent main portal vein.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with cirrhosis now with GI bleed// full
abdominal ultrasound to eval ascites, portal HTN, OVT and liver and gall
bladder.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___.
FINDINGS:
LIVER: The patent parenchyma is coarsened. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. There is
small volume ascites.
The main portal vein is patent with hepatopetal flow. The right anterior and
posterior portal veins are also patent with hepatopetal flow. The left portal
vein is not well seen, but limited images demonstrate hepatopetal flow,
although this is not wall-to-wall.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The gallbladder is surgically absent.
PANCREAS: The pancreas is not well seen, largely obscured by overlying bowel
gas.
SPLEEN: Normal echogenicity.
Spleen length: 16.3 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 9.8 cm
Left kidney: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with splenomegaly and ascites consistent with portal
hypertension.
2. Poorly visualized left portal vein, with slightly diminished waveforms and
incomplete color flow may be technical, although it is difficult to exclude a
nonocclusive left portal vein thrombus. If clinically appropriate, a
dedicated liver CT with portal venous phase could be obtained.
3. Patent main, right anterior and right posterior portal veins.
RECOMMENDATION(S): Consider a CT liver CT with portal venous phase if
clinically appropriate.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.9
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 123.0
dbp: 77.0
level of pain: 10
level of acuity: 2.0 | ========================
BRIEF SUMMARY
========================
___ is a ___ year old women with EtOH cirrhosis
complicated by portal hypertension, esophageal variceal
bleeding, and small volume ascites who presented with
hematemesis, found to have severe esophagitis on EGD with no
clear evidence for variceal hemorrhage.
She also has a history of a bile duct injury from a distant
cholecystectomy, and is s/p roux-en-Y hepaticojejunostomy with
separate hepaticojejunostomy to right posterior duct. Given the
findings on her EGD and that her bleeding stabilized, it was not
felt like she needed any additional evaluation to look for
alternative bleeding sites such as a marginal ulcer.
She was given 1 blood transfusion on admission but her counts
remained stable for 2 days and she was discharged with
hepatology follow up for repeat outpatient EGD, high dose PPI
therapy, and sucralfate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Tylenol overdose, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with lupus, metabolic disease with DM and
blindness, and recent admission for Tylenol overdose (discharged
___ , presenting from her mental health provider after
taking "3 handfuls" of 500 mg Tylenol capsules at 1400 on
___. States the purpose of this was to relieve her chronic
pain rather than an intent to harm herself, stating "I would
have taken way more pills than that if I wanted to kill myself".
In the ED, she denied SI. No fevers/chills, no abdominal pain,
no N/V/diarrhea. Of note, she also has not been taking her
insulin.
In the ED:
- initial VS were: 97.7 110 133/88 16 100% RA
- exam notable for: lethargy, intermittently uncooperative
- labs notable for: serum acetaminophen 308, Utox + for benzos,
glucose 525, LFts normal, lactate normal
- psych was consulted: agree with admission to medicine, unable
to assess safety evaluation secondary to delirium
- started on NAC infusion, received 3L LR and 10 units regular
insulin
- VS prior to transfer: 104 108/62 22 100% RA
On arrival to the floor, patient reports diffuse body pains.
She was otherwise calm and denied any SI. Her repeat FSGs was
390s and received 12 Units of Humalog. She was continued on LR
continuous fluids, NAC gtt, and continued on her home insulin
regimen.
Past Medical History:
-Type 1 Diabetes
-Mitochondial Myopathy
-Depression
-Hypertriglyceridemia
-HypoMagnesemia
-Insomnia
-Gait Disorder
-Irregular menses
-Legal Blindness
-Migraines
-Benign Hypertension
-Sleep Apnea
-Ambien and benzodiazepine abuse
-Gastroparesis
-SLE
-acetaminophen overdose
Social History:
___
Family History:
Father- unknown - no relationship with him
Mother- ___
Sister- mitochondrial myopathy
Great-grandmother- colon cancer
Grandmother- breast cancer
Physical Exam:
=====================
ADMISSION EXAM
=====================
VS T 97.5 HR 94 BP 132/94 RR 20 SpO2 100% RA
GENERAL: Tired appearing but in NAD
HEENT: Sclera anicteric, dry mucous membranes, no OP lesions
NECK: Supple, no JVD or cervical lymphadenopathy
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, NT, ND. Normoactive bowel sounds
EXTREMITIES: No ___ edema
PULSES: 2+ DP pulses bilaterally
NEURO: Moving all extremities with purpose, no facial
asymmetry.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=====================
DISCHARGE EXAM
=====================
VITALS:98.8 98.3 116/74(90-110) 88(80s) 100RA BG 24 hrs
110-200s
GENERAL: Lying in bed in no distress
NECK: Supple, no JVD or cervical lymphadenopathy
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, NT, ND. Normoactive bowel sounds
EXTREMITIES: No ___ edema
PULSES: 2+ DP pulses bilaterally
PSYCH: calm
SKIN: Patch of grouped vesicles linearly arranged on right
upper thigh with background of pinkish erythema, this also
extends to hip area on right hip. All lesions are crusted over.
Pertinent Results:
==================
ADMISSION LABS
=================
___ 06:19PM BLOOD WBC-3.8*# RBC-4.72 Hgb-12.7 Hct-38.0
MCV-81* MCH-26.9 MCHC-33.4 RDW-16.0* RDWSD-45.5 Plt ___
___ 06:19PM BLOOD Neuts-48.6 ___ Monos-20.3*
Eos-0.3* Baso-0.5 Im ___ AbsNeut-1.85 AbsLymp-1.11*
AbsMono-0.77 AbsEos-0.01* AbsBaso-0.02
___ 07:13AM BLOOD ___ PTT-27.8 ___
___ 06:19PM BLOOD Glucose-525* UreaN-16 Creat-0.9 Na-131*
K-4.3 Cl-93* HCO3-20* AnGap-22
___ 06:19PM BLOOD ALT-17 AST-22 AlkPhos-70 TotBili-0.4
___ 07:13AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.4*
___ 09:58AM BLOOD %HbA1c-11.8* eAG-292*
___ 06:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-308*
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 06:28PM BLOOD Lactate-1.4
==================
MICROBIOLOGY
==================
___ 1:27 am URINE Source: ___.
**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.
BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML..
==================
IMAGING
=================
RUQ US ___: IMPRESSION:
The portal veins are patent with hepatopetal flow.
CT HEAD ___: IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of acute intracranial hemorrhage.
==================
DISCHARGE LABS
=================
___ 06:28AM BLOOD WBC-1.9* RBC-3.25* Hgb-8.8* Hct-28.6*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.6* RDWSD-58.7* Plt ___
___ 06:28AM BLOOD Glucose-220* UreaN-18 Creat-0.7 Na-135
K-4.1 Cl-104 HCO3-21* AnGap-14
___ 06:28AM BLOOD ALT-37 AST-32 AlkPhos-51 TotBili-0.3
___ 06:11AM BLOOD ALT-58* AST-35 AlkPhos-49 TotBili-0.3
___ 05:54AM BLOOD ALT-97* AST-49* AlkPhos-64 TotBili-0.4
___ 06:28AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0
==================
WORKUP FOR UNDERLYING LIVER DISEASE
==================
___ 02:02AM BLOOD ___ * Titer-GREATER TH
___ 02:02AM BLOOD CEA-2.7 AFP-1.9
___ 02:02AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 02:02AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
___ 02:02AM BLOOD HIV Ab-Negative
___ 02:02AM BLOOD IgG-1042 IgA-466* IgM-86
___ 02:02AM BLOOD HCV Ab-NEGATIVE
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with acute Tylenol toxicity and liver failure
with worsening LFT and abdominal pain // Assess for portal vein thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is no evidence of stones.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
The main portal vein, the right anterior, the right posterior and the left
portal vein have wall-to-wall hepatopetal color flow.
IMPRESSION:
The portal veins are patent with hepatopetal flow.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with history of mitochondrial disorder, status
post Tylenol overdose, now with increasing somnolence and confusion. Evaluate
for acute intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP (Head) = 765 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci unchanged in size and configuration. ___ cisterna magna versus is
arachnoid cyst is stable.
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 abnormality.
2. No evidence of acute intracranial hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tylenol OD now with fever // ?PNA
?PNA
IMPRESSION:
In comparison with the study of ___, there again are relatively
low lung volumes that accentuate the transverse diameter of the heart. No
evidence of vascular congestion, pleural effusion, or acute focal pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SI, Overdose
Diagnosed with Poisoning by 4-Aminophenol derivatives, accidental, init
temperature: 97.7
heartrate: 110.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | ___ with DM1, SLE, borderline personality disorder, and recent
acetaminophen overdose, who presents after intentional
acetaminophen overdose. Pt had been discharged 2 days prior to
admission after intentionally taking 30 tabs acetaminophen,
which she stated was due to pain. She had been evaluated by
psychiatry at that time and felt to be safe for discharge.
However, 2 days after discharge, she took approximately 60 tabs
acetaminophen. She again denied suicidal ideation, but presented
to her psychiatrist just after taking the dose. She was placed
under ___ and admitted to the medicine service. The 4
hour acetaminophen level was 308. She was treated with
N-acetylcysteine infusion. However, her LFTs worsened, with
transaminases peaking at 4000s/6000s. INR peaked at 2.9, lactate
5.5 and Tbili 2.7. She was briefly transferred to the SICU where
she was treated supportively with a higher dose NAC infusion and
aggressive management of electrolyte abnormalities and
hyperglycemia leading to overall improvement. She was evaluated
by Hepatology, Transplant Surgery and did not require liver
transplantation. She was evaluated for other causes of
underlying liver disease, but testing was negative. Her LFTs
continued to improve to normal levels. She should not use
acetaminophen for six months. She was maintained on 1:1 pending
placement in inpatient psychiatry unit. There was concern for
lack of capacity, so guardianship paperwork was filed.
She had significant hyperglycemia in the setting of insulin
noncompliance. She was followed by the ___ diabetes service
with titration of her insulin doses and improvement in glycemic
control. Rheumatology was consulted regarding her lupus
management. She showed no evidence of a lupus flare. She was
continued on prednisone 5mg po daily, hydroxychloroquine 300mg
po daily. Methotrexate was held initially and then restarted
once LFTs noramlized. Additionally while in the hospital she
developed zoster in an L1 distribution, which was treated with
valacyclovir for 14 days. Pt was medically cleared for transfer
to psychiatry service.
===============
ACUTE ISSUES
===============
#Intentional Acetaminophen Overdose/Acute Liver Injury: Pt
presented after taking 60 tabs of acetaminophen. The 4 hour
acetaminophen level was 308. She was treated with
N-acetylcysteine infusion. However, her LFTs worsened, with
transaminases peaking at 4000s/6000s. INR peaked at 2.9, lactate
5.5 and Tbili 2.7. She was briefly transferred to the SICU where
she was treated supportively with a higher dose NAC infusion and
aggressive management of electrolyte abnormalities and
hyperglycemia leading to overall improvement. She was evaluated
by Hepatology, Transplant Surgery and did not require liver
transplantation. She was evaluated for other causes of
underlying liver disease, but testing was negative. Her LFTs
continued to improve to normal levels. She should not use
acetaminophen for six months. Management of underlying
psychiatric disorder, as below.
#Borderline personality disorder: with intentional acetaminophen
overdose as discussed. She was evaluated by psychiatry and found
to need inpatient management. She was placed on ___ and
transfered to inpatient psych. Monitored with 1:1 sitter.
#Lack of capacity: Patient was not thought to have capacity due
to refusing insulin injections and fingersticks. Guardianship
process was started.
#Diabetes Mellitus Type 1: Pt presented with diabetic
ketoacidosis in setting of insulin noncompliance due to desire
to lose weight. She was treated with insulin with resolution of
anion gap metabolic acidosis. She was followed by ___ service
during her hospitalization with titration of her insulin
regimen. Her blood sugars were controlled in the range of
100s-200s at the time of transfer. She will continue to be
followed on the ___ service.
#Zoster: Pt with rash characteristic of herpes zoster with
burning sensation along upper R thigh in L1 distribution. She
was kept on contact precautions until her rash crusted over. She
was treated with valacyclovir 100 mg TID x14 days (___)
and was treated with lidocaine cream.
===============
CHRONIC ISSUES
===============
# SLE: Pt has a known history of SLE. ___ positive, 1:1250
titer. She had been followed by Dr. ___ had terminated
care and was not following with anyone. She was evaluated by
rheumatology in house to optimize her regimen. She had no
clinical evidence for lupus flare, and C3, C4, dsDNA were
normal/negative. Her home methotrexate was held due to liver
dysfunction, but then restarted once LFTs normalized. She was
continued on Hydroxychloroquine Sulfate 300 mg PO/NG DAILY. She
was tapered down on prednisone to 5mg po daily to prevent
adrenal insufficiency. She has outpatient follow-up scheduled
with rheumatology.
# Neuropathy: Appears to be at baseline mental status, no
significant sedation. She was continued on gabapentin BID.
================
TRANSITIONAL ISSUES
===============
-continue valacyclovir 1000 mg PO Q8H (Last day: ___
-trend QTc, as haloperidol was started for sleep.
-continue to monitor fingersticks and give insulin as per
sliding scale. If patient plans an overnight snack, she should
be given an additional dose of insulin according to the bedtime
sliding scale.
-rheum follow-up: Dr. ___ on ___
# CODE: Full (confirmed)
# CONTACT: HCP: sister, ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Flomax / metoprolol / Lisinopril / grapefruit / cranberry
Attending: ___.
Chief Complaint:
fatigue leukocytosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with a medical history notable
for CAD, severe AS s/p transfemoral TAVR, pAfib (on warfarin),
anemia, and high grade adenocarcinoma of right hard palate
maxilla s/p right subtotal maxillectomy and right neck
dissection ___ presenting with fatigue and elevated white
blood cell count.
Patient lives at an independent living facility with an
in-house physician. A full set of labs was obtained on ___
and the patient was noted to have a white blood cell count of
27,000. Patient was referred to ___ for further
management.
Per history obtained in the ED, patient describes generalized
weakness, fatigue, and chills. He notes urinary frequency. Of
note, patient does self cath in the morning and night. Patient
otherwise has no complaints of nausea, vomiting, chest pain,
shortness of breath, or a new cough. Patient does not have any
abdominal pain. Patient does not have any diarrhea or
constipation.
Of note, the patient did fall a few days ago. He did not strike
his head. He did not lose consciousness. Patient states that he
fell onto his sacrum. Patient is on warfarin for atrial
fibrillation.
In the ED, initial vitals were: T 97.6 BP 125/78 HR 118 RR 18
O2
96% RA
Exam was notable for:
- CV: Irregular, not tachycardic
Labs were notable for:
- WBC 13.5, Hgb 8.7
- BUN 59, Cr 2.1
- ALT 27, AST 43, AP 84, Tbili 0.2, Alb 3.2, lip 23
- INR 1.3
- Lactate 1.2
- Flu A/B negative
- UA 136 WBC, lg leuk
Studies were notable for:
- ___ CT head w/o contrast
1. No acute intracranial hemorrhage. No large territorial
infarction. No acute intracranial findings.
2. Postoperative changes of palate resection for prior mass
with
obturator prosthesis in place.
The patient was given:
- 1L NS, IV aceteminophen 1000mg, IV Piperacillin-tazobactam
4.5mg
While in the ED, patient became hypotensive with SBP 90's. His
lactate rose from 1.2 to 3.5. He received an additional 1.5L
fluids and pressures improved with resolution of lactate.
Vitals on transfer: BP 108/62 HR 62 RR 12 O2 99% 1L NC
On arrival to the floor, patient was in no acute distress. He
was conversive, but was not sure exactly why he was in the
hospital. History taking was complicated by his inability to
recall recent events. Per his daughter, ___, he has been
more tired and weaker for the last few weeks with intermittent
chills. She also reports that he has had an abrupt decline in
his walking ability, as he usually is able to walk to the local
store without
assistance, but over the last month has required a walking cane
and now a rolling walker.
REVIEW OF SYSTEMS:
==================
Reports increased urinary frequency of unknown duration. Denies
headache, changes in vision, chest pain, shortness of breath,
cough, abdominal pain, changes in bowel movements, hematuria,
dysuria, N/V, f/v, night sweats, and weight loss. Otherwise,
10-point review of systems was within normal limits.
Past Medical History:
Hypertension
Urinary Frequency with BPH- prostate elevated 7.8 in ___
Mitral Valve Insufficiency/AS (confirmed per ___ ECHO at ___)
Allergic Rhinitis
___: Total 235, LDL 138, HDL 46
Mild chronic anemia
Pre-diabetes
Stage 3 CKD
Alzheimers dementia
Diverticuli of urinary bladder ___
Incidental 4mm lung mass on CT ___
Severe AS s/p TAVR ___, EF 47%)
AFib on Coumadin (h/o intra-ocular hemorrhage, still INR goal
___
Anemia (h/o iron deficiency, has declined repeat colonoscopy)
Adenocarcinoma of R hard palate
Social History:
___
Family History:
Mother-deceased age ___, pancreatic cancer.
Father-deceased age ___, stroke.
No siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.5 BP 106/58 HR 60 RR 20 O2 97% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi
or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS
=========================
___ 05:57PM BLOOD WBC-13.5* RBC-3.09* Hgb-8.7* Hct-27.9*
MCV-90 MCH-28.2 MCHC-31.2* RDW-15.8* RDWSD-51.8* Plt ___
___ 05:57PM BLOOD Neuts-81.5* Lymphs-12.3* Monos-5.5
Eos-0.2* Baso-0.1 Im ___ AbsNeut-11.03* AbsLymp-1.66
AbsMono-0.74 AbsEos-0.03* AbsBaso-0.01
___ 05:57PM BLOOD ___ PTT-23.8* ___
___ 05:57PM BLOOD Glucose-103* UreaN-59* Creat-2.1* Na-135
K-4.7 Cl-100 HCO3-22 AnGap-13
___ 05:57PM BLOOD ALT-27 AST-43* AlkPhos-84 TotBili-0.2
___ 08:45AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.1 Iron-11*
___ 08:45AM BLOOD calTIBC-200* Hapto-327* Ferritn-306
TRF-154*
___ 08:29PM BLOOD Lactate-1.2
___ 02:42AM BLOOD Lactate-3.5*
___ 08:45AM BLOOD WBC-24.8* RBC-2.66* Hgb-7.5* Hct-23.9*
MCV-90 MCH-28.2 MCHC-31.4* RDW-15.6* RDWSD-51.3* Plt ___
___ 09:52PM URINE Color-Straw Appear-Hazy* Sp ___
___ 09:52PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:52PM URINE RBC-3* WBC-136* Bacteri-NONE Yeast-NONE
Epi-0
___ 09:52PM URINE Hours-RANDOM UreaN-574 Creat-57 Na-27
MICROBIOLOGY
=========================
___ BCx: no growth to date
___ BCx: no growth to date
___ BCx: no growth to date
IMAGING
===========================
___ RENAL ULTRASOUND: No hydronephrosis. No suspicious
renal lesions. Trace right perinephric fluid appears similar to
a prior CT from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY hypertension
4. Docusate Sodium (Liquid) 100 mg PO BID constipation
5. Donepezil 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY BPH
7. Memantine 10 mg PO BID
8. Terazosin 10 mg PO DAILY BPH
9. OxycoDONE Liquid 2.5-5 mg PO Q6H:PRN Pain - Moderate
10. Sodium Chloride Nasal ___ SPRY NU 5X/DAY
11. Warfarin 2 mg PO DAILY16 Atrial fibrillation
12. Multivitamins 1 TAB PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Pravastatin 80 mg PO QPM
16. Vitamin D ___ UNIT PO DAILY
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
18. amLODIPine 2.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
URINARY TRACT INFECTION
SEPSIS
BACTEREMIA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with weakness and elevated wbc// Please r/o cardiopulmonary
process
COMPARISON: Chest CT from ___.
FINDINGS:
Lung volumes are relatively low with bibasilar atelectasis. There is no
evidence of focal consolidation or pulmonary edema. No evidence of
pneumothorax or large pleural effusion. Mediastinal and hilar contours are
normal. Cardiac silhouette is enlarged. Aortic valve replacement is again
noted. No evidence of displaced fracture. Prosthetic aortic valve is noted.
IMPRESSION:
No evidence of pneumonia. No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall on a blood thinner// Rule out 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 18.0 s, 18.6 cm; CTDIvol = 48.6 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Prior head CT ___, MRI ___, CT neck ___
FINDINGS:
No acute intracranial hemorrhage. No large territorial infarction. No mass or
mass effect. Mild involutional changes of the sulci and ventricles for age.
There are bilateral subcortical white matter hypodensities, which are
consistent with sequela of chronic microangiopathy.
There is no evidence of fracture. Degenerative changes again seen at the left
temporomandibular joint. Postoperative changes of prior palate resection are
noted with obturator prosthesis in place. There is moderate thickening and
postsurgical change of the right maxillary sinus. The left maxillary sinus as
well as the bilateral ethmoid air cells and sphenoid sinuses are clear. The
right mastoid air cells are opacified, the left mastoid air cells are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage. No large territorial infarction. No
acute intracranial findings.
2. Postoperative changes of palate resection for prior mass with obturator
prosthesis in place.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with hx of BPH, A-fib admitted for treatment of
GNR bacteremia and UTI// r/o hydronephrosis and abscesses in both kidneys
please
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Prior CT performed ___
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally. There
is a trace amount of perinephric fluid on the right around the inferior pole
of the right kidney, which appears to be consistent with previously
demonstrated trace pocket of fluid seen on the prior CT.
Right kidney: 9.7 cm
Left kidney: 10.2 cm
The bladder is decompressed around a inflated Foley catheter balloon.
IMPRESSION:
No hydronephrosis. No suspicious renal lesions. Trace right perinephric
fluid appears similar to a prior CT from ___.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: 91 mo chronic urinary retention(straight caths at home) admitted
with sepsis, gram negative rod bactermia, and UTI, persistent bacteremia c/f
prostatis vs perinephric asbcess// PROSTATE CUTS please; prostatis vs nephric
abscess?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 4.0 s, 53.2 cm; CTDIvol =
16.1 mGy (Body) DLP = 858.0 mGy-cm. 2) Spiral Acquisition 1.0 s, 13.7 cm;
CTDIvol = 13.1 mGy (Body) DLP = 178.5 mGy-cm. 3) Stationary Acquisition 0.6 s,
0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 4) Stationary Acquisition
0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 5) Stationary
Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP = 21.8 mGy-cm. Total
DLP (Body) = 1,062 mGy-cm.
COMPARISON: CT chest from ___.
CT of the abdomen pelvis without contrast from ___.
FINDINGS:
LOWER CHEST: Small right and trace left nonhemorrhagic pleural effusions with
mild adjacent atelectasis. Post TAVR, partially visualized. Trace
pericardial effusion, partially visualized.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates mildly heterogeneous attenuation
throughout. Simple hepatic cysts in the right hepatic lobe measure up to 4.3
cm. Several scattered subcentimeter hypodensities are too small to
characterize but statistically most likely represents cysts. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is normal.
PELVIS: Diffuse bladder wall thickening with surrounding inflammatory
stranding and moderate-sized bladder dome diverticulum. Multiple locules of
air within the urinary bladder.
REPRODUCTIVE ORGANS: Prostate gland appears enlarged measuring 4.8 x 3.9 x
5.2, 51 cc's. No prostatic abscess.
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: No definite acute fracture. Mild compression deformity with transverse
fracture lucency through the anterior superior endplate and slight surrounding
sclerosis involving the L2 vertebral body is new from ___ (602:34;
601:40). Mild superior endplate deformity involving the L1 vertebral body
appears unchanged from ___. No retropulsion at either of these levels.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Diffuse bladder wall thickening with surrounding inflammatory stranding,
findings concerning for infection. Multiple locules of air within the urinary
bladder are likely related to recent instrumentation, given history of
catheterization. No evidence of abscess.
2. Moderate-sized bladder dome diverticulum, stable from ___.
3. Small right pleural effusion and trace left pleural effusions.
4. Age-indeterminate mild compression deformity with transverse fracture
lucency through the anterior superior endplate of the L2 vertebral body.
Chronic mild compression deformity of the L1 vertebral body, unchanged.
NOTIFICATION: The findings were discussed with ___, Medical Student by
___, M.D. on the telephone on ___ at 2:41 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx CAD, AS s/p TAVR, Afib on warfarin
admitted for sepsis iso enterobacter bacteremia ___ UTI. Noted newly altered
with hypoxia to 88% on RA with fever to 103 after possible small aspiration
event// ?aspiration, PNA, volume overload
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
Low lung volumes are noted. There is indistinctness of the pulmonary
vasculature and mild patchy parenchymal opacities in the lung bases which may
represent mild developing pulmonary edema. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable
in appearance. No acute osseous abnormalities are identified.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Urinary tract infection, site not specified, Elevated white blood cell count, unspecified
temperature: 97.6
heartrate: 118.0
resprate: 18.0
o2sat: 96.0
sbp: 125.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | PATIENT SUMMARY:
================
___ with history of CAD, aortic stenosis s/p TAVR,
adenocarcinoma maxilla s/p
resection, A-fib (on warfarin with subtherapeutic INR at
admissin___), chronic urinary retention (straight caths at home)
admitted with sepsis, gram negative rod bactermia, and UTI,
treated with zosyn narrowed to ceftriaxone after ___ BCx/UCx
returned positive for pan-sensitive Enterobacter Cloacae, course
c/b persistent bacteremia, broadened to cefepime d/t concern for
induced AMP-C resistance.
ACUTE/ACTIVE ISSUES:
====================
# Sepsis with Enterobacter UTI, complicated urinary tract
infection: Patient presented with urinary tract infection and
sepsis, afebrile but with leukocytosis and eosinopenia. Patient
had renal u/s without hydronephrosis to rule out infected stone.
Initially started on zosyn, then narrowed to ceftriaxone after
___ blood culture showed pan-sensitive Enterobacter Cloacae.
Patient had persistent bacteremia on ___ despite presumptively
adequate antibiotic coverage and was broadened to cefepime due
to concern for induced AMP-C resistance. Also evaluated for
adequate source coverage with TTE, CT abdomen/pelvis with
prostate cuts, which did not reveal other infection sources.
-straight cath frequency in the hospital was q6h, plan for
>3x/day at home
-ertapenem daily through midline for 14 days after negative
blood culture (___)
# ___: Patient admitted with ___, resolved during admission.
Most likely etiology is pre-renal iso sepsis. Possible
obstruction with history of BPH. Renal u/s did not show
hydronephrosis.
# Anemia: During admission, patient had Hgb of 6.9 that improved
with 1 unit RBC transfusion. Home ferrous sulfate was being held
d/t infection. Iron was decreased at 11, iron studies consistent
with anemia of chronic disease. No concern for acute bleed.
# Subtherapeutic INR/AFib: Patient was on warfarin for pAfib
with goal INR ___, INR was subtherapeutic at admission (1.3) and
improved very slightly during admission to 1.5. We increased
warfarin dose from 2.5->4->5. Previously followed by PCP, but
per patient's daughter preference, will be followed by ___
___ clinic at discharge.
CHRONIC/STABLE ISSUES:
======================
# HTN: Patient was normotensive on arrival, then developed
relative hypotension in
setting of sepsis/developing shock. Home amlodipine 2.5 was
briefly held, restarted after BPs became elevated.
-Unclear if patient was taking chlorthalidone 12.5, held during
hospitalization and not restarted at discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amiodarone / Moexipril / hctz
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CAD s/p BMS to OM in ___ and medicaly managed NSTEMI in
___, Afib/SS s/p ___ who presents with malaise and loose stool x
5 days. Patient lives in nursing home and has been refusing food
and looked unwell for the last few days and so was sent in by
visiting physician despite ___ form (also DNR/DNI). Loose stools
x 5 this AM. Per ___ and with help from interpreter, patient also
complains of orthopnea. Denies nausea, just does not have
appetite. Patient is mentating well and is not confused at this
time. Discussion was had with the son as the ___ diagnosed the pt
with UTI, possibly cuasing her decreased appetitis. After
discussion this with her GOC in mind, son agreed with
hospitalization to treat UTI and hydrate.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: ___
-PACING/ICD: dual chamber PPM
3. OTHER PAST MEDICAL HISTORY:
Atrial Fibrillation
Sick Sinuse Syndrome s/p ___
2-vessel CAD, s/p BMS-OM ___
Osteoporosis
Glaucoma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.6 149/92 66 20 100%RA, weight 121 (was 117 in ___
GENERAL: Pt was wiping her buttocks vigorously on arrival to the
room, seems to be in pain due to her buttock issues (see below)
HEENT: NCAT, PERRLA, prominent conjuctiva, anicteric, oral
cavity without thrush, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs but distant
LUNG: LLL base crackles but otherwise CTAB, no wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, 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 grossly, ambulating in the room
SKIN: thin skins with e/o senile prupura
RECTUM: severe excoriations in the skin, multiple hemorrhoids
but unable to determine if thrombosed given pt in pain
DISCHARGE PHYSICAL EXAM:
VS - 97.7 148/77 63 16 98% on RA
General: NAD
HEENT: EOMI, poor dentition, dry mucus membranes, no
Neck: No LAD, trachea midline
CV: S1, S2, RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, NT/ND
GU: Rectal exam reveals excoriations, inflammation, small
hemarroid appreciated does not appear to be thrombosed, no
foley, tendernes to palpation over inflammed tissue
Ext: No cyanosis, clubbing, or edema
Neuro: Awake, alert, oriented to person and place only, moving
all extremeties equally anti-gravity
Skin: No rashes appreciated
Pertinent Results:
LABS ON ADMISSION:
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 07:50PM URINE RBC-1 WBC-35* BACTERIA-FEW YEAST-NONE
EPI-1
___ 07:06PM LACTATE-2.5*
___ 07:00PM GLUCOSE-98 UREA N-40* CREAT-1.3* SODIUM-147*
POTASSIUM-4.9 CHLORIDE-110* TOTAL CO2-22 ANION GAP-20
___ 07:00PM TSH-3.1
IMAGING:
CHEST X-RAY ___:
Trace right and small left pleural effusion, slightly larger
when compared to prior. No focal consolidation.
MICROBIOLOGY DATA:
___ 5:47 am STOOL
C. difficile DNA amplification assay (Final ___:
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
LABS ON DISCHARGE:
___ 06:58AM BLOOD WBC-5.3 RBC-4.50 Hgb-13.7 Hct-43.3 MCV-96
MCH-30.4 MCHC-31.6 RDW-15.1 Plt ___
___ 06:58AM BLOOD Glucose-98 UreaN-32* Creat-1.2* Na-145
K-4.8 Cl-112* HCO3-26 AnGap-12
___ 06:58AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
___ 08:27AM BLOOD Lactate-2.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 12.5 mg PO Q6H:PRN agitation
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. Acetaminophen 650 mg PO Q4H:PRN pain
5. Bisacodyl ___AILY:PRN constipation
6. Aspirin 81 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Atorvastatin 40 mg PO DAILY
10. Nuedexta (dextromethorphan-quinidine) ___ mg oral BID
11. Exelon (rivastigmine;<br>rivastigmine tartrate) 1.5 mg oral
BID
12. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
13. Ranitidine 150 mg PO QHS
14. Mirtazapine 7.5 mg PO QHS
15. Psyllium 1 PKT PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Mirtazapine 7.5 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. Ranitidine 150 mg PO QHS
9. TraZODone 12.5 mg PO Q6H:PRN agitation
10. Hydrocortisone (Rectal) 2.5% Cream ___ID
RX *hydrocortisone [ProctoCream-HC] 2.5 % 1 Application cream(s)
rectally twice a day Refills:*0
11. Miconazole Powder 2% 1 Appl TP TID
RX *miconazole nitrate 2 % Apply powder to rectum and
surrounding area three times a day Disp #*3 Spray Refills:*0
12. Bisacodyl ___AILY:PRN constipation
13. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
14. Exelon (rivastigmine;<br>rivastigmine tartrate) 1.5 mg oral
BID
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
17. Nuedexta (dextromethorphan-quinidine) ___ mg oral BID
18. Psyllium 1 PKT PO DAILY
19. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth Q6 hours Disp #*84
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis: Clostridium difficile colitis, dehydration
Secondary Diagnosis: Coronary artery disease, atrial
fibrillation, sick sinus syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with weakness, dyspnea, LLL crackles // eval
for PNA
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are hyperinflated. There is a small left-sided pleural effusion,
larger when compared to prior. Trace right pleural effusion is also noted.
The lungs are clear of consolidation or edema. Moderate cardiomegaly is again
noted.
Atherosclerotic calcifications noted at the aortic arch. Left chest wall dual
lead pacer again noted. Lower thoracic superior compression deformity is again
seen.
IMPRESSION:
Trace right and small left pleural effusion, slightly larger when compared to
prior. No focal consolidation.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with URIN TRACT INFECTION NOS, ATRIAL FIBRILLATION, HYPEROSMOLALITY
temperature: 97.4
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 61.0
level of pain: 13
level of acuity: 2.0 | ___ hx MI s/p PCI in ___, medically managed NSTEMI ___,
Afib/SSS s/p PPM p/w malaise, loose stool x 5 days admitted
despite MOLST form specifying DNR/DNI/do not hospitalize after
discussion with her son.
# Diarrhea-patient mildly hypernatremic to 147 with mild ___ (Cr
1.3), given 1.5L IVF with improvement in hypernatremia and ___
and dehydration. The patient's rectal exam was significant for
excoritions and erythema and external hemarroids which were
treated with miconazole powder and hydrocortisone cream. She
denied any pain at rest or pain with bowel movements. A stool
sample was C diff positive for which she received PO vancomycin
QID. She will continue the vancomycin at her nursing home until
___ to complete a 14 day course. In light of her history of
hypothyroidism, a TSH was checked and was within normal limits.
# Chest pain-The patient complained of chest pressure while
admitted, an EKG was negative for ischemic changes and a
troponin was negative. The chest pressure resolved with one dose
of nitroglycerin.
# Positive Urinalysis: Likely a contaminated sample in the
setting of the patient wiping frequently and having diarrhea,
urine culture growing gram negative rods which is consistent
with contamination. The patient received 1 dose of ceftriaxone
in the ___ but was not treated upon admission to the medical
floor and does not require further antibiotics.
# Rectal Excoriations: Likely secondary to wiping and itching
from diarrhea and hemarrhoid, area seems wet, extreme erythema
concerning for fungal infection and hemarroid apparent, does not
seem to be thrombosed or to be causing the patient discomfort.
The patient received hydrocortisone cream for itching and
miconazole powder for fungal infection which she should continue
at her nursing home until the erythema improves.
# ___: Likely due to pre-renal/dehydration and poor PO intake.
The patient received IV fluids in the ER and once transferred to
the medical floor with some improvement in her kidney function.
She should continue to drink plenty of fluids to stay hyrated
while she has diarrhea.
# Dehydration/Hypernatremia: Poor PO intake in the setting of
diarrhea led to her being hemoconcentrated and having
hypernatremia. After receiving IV fluids, her lactate trended
down, her creatinine improved, and her hypernatremia resolved.
She should continue to drink plenty of fluids once transferred
back to her nursing home.
# CAD: Cont ASA, Metoprolol, statin. The patient had one episode
of chest pressure while hospitalized, an EKG was obtained and
showed no signs of ischemia. A troponin level was check and was
negative. The chest pressure resolved with one dose of
nitroglycerin.
# Hypothryodisim: Stable, TSH wnl. Cont Levothyoxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tetracycline / Nabumetone
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumar Puncture
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history
of
rapidly progressive glomerulonephritis in ___ c/b CKD (baseline
Cr ~1.9), hypothyroidism, and HLD who presents for evaluation of
headache x10 days. She first developed a headache on ___.
Earlier that day, she had gone to the dentist and taken
amoxicillin. In the evening, she developed a bifrontal headache
which was throbbing, no photophobia/phonosensitivity, no nausea,
no diplopia. The headache was a ___ in severity. She did not
take anything for it. The headache became less severe, a ___,
but was constant. It was bifrontal and occasionally occipital.
Does endorse some neck stiffness, denies meningismus. Not worse
in the mornings, not exacerbated with valsalva, not interrupting
sleep. Patient does not have migraines and does not typically
have headaches. After 2 days of constant headache, Ms.
___
went to her PCP who recommended that she try Tylenol. She took
in twice, but it did not help, so she stopped taking it. As the
headache persisted, she went to the hospital for further
evaluation. There, they did blood work and a head CT which was
reportedly normal. They prescribed her Tramadol. Pt took
tramadol several times, but it did not help, so she stopped.
The
headache persisted, but was not becoming more severe. She went
to
see her PCP again who prescribed fiorocet, which again, did not
help. Has had depressed appetite, but taking in plenty of
fluids. Feels overall tired/weak and has had some chills. Feels
that her walking is a little bit more difficult than usual. She
is not falling to one side or the other. Did have a left knee
replacement in ___. No history of blood clots. Last
mammogram in ___, last colonoscopy ___ years ago, both were
normal per patient.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Osteoporosis
Lithotripsy for renal stones ___ years ago
Hyperlipidemia
COPD/emphysema
Hypothyroid
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.4 HR 81 BP 145/86 RR 16 O2 100 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated; surgical scar on left
knee
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ ___ 4+* 5 5 5 5 5
R 5 ___ ___ 5- 5 5 5 5 5
*limited by pain
-Sensory: No deficits to light touch, proprioception. Slightly
decreased sensation to pinprick, cold sensation in distal lower
extremities to knee bilaterally and distal upper extremities to
elbow bilaterally. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Gait narrow based, steady, but places
most of weight on right leg (knee replacement on L). Romberg
mildly present.
DISCHARGE EXAM
Normal neurologic exam, alert and awake with intact cranial
nerves and full strenegth throughout.
Pertinent Results:
___ 12:10AM BLOOD WBC-9.0 RBC-4.13*# Hgb-12.7# Hct-36.6#
MCV-89 MCH-30.7 MCHC-34.7 RDW-13.6 Plt ___
___ 01:10PM BLOOD ESR-39*
___ 10:00PM BLOOD Glucose-73 UreaN-27* Creat-1.8* Na-134
K-4.1 Cl-104 HCO3-18* AnGap-16
___ 01:10PM BLOOD CRP-38.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Do not drive, drink alcohol or operate heavy machinery while
taking this medication.
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
5. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Viral meningitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ with headache. Rule out mass or CVT.
COMPARISON: None.
TECHNIQUE: Sagittal T1-weighted sequence, axial FLAIR, axial T2, magnetic
susceptibility and diffusion-weighted images were obtained. Subsequently, 2D
time-of-flight MRV was performed.
FINDINGS:
There is mild cerebral and cerebellar volume loss. Normal ventricular size. No
mass, edema or infarct is demonstrated. No diffusion abnormality is present.
Normal flow related enhancement in the dural venous sinuses and internal
cerebral veins.
Minor foci of increased FLAIR-signal are noted involving the periventricular
white matter, and subcortical white matter in the left frontal and parietal
lobe that are non-specific.
The orbits are unremarkable. There is minor mucosal thickening involving the
ethmoid air cells. Normal bone marrow signal is demonstrated.
IMPRESSION:
No mass or cerebral venous sinus thrombosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEADACHE
Diagnosed with HEADACHE
temperature: 97.4
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 145.0
dbp: 86.0
level of pain: 3
level of acuity: 3.0 | ___ woman who was admitted with headache x 10 days, with
a normal neurologic exam and no significant MRI findings,
diagnosed with aseptic meningitis.
#ASEPTIC MENINGITIS - Initially placed on vancomycin,
ampicillin, ceftriaxone and acyclovir until CSF gram stain
negative and culture negative x72 hours, Lyme and HSV negative.
Arbovirus is pending upon discharge. Her ___ was negative, ESR
and CRP mildly elevated consistant with mild inflammation
secondary to aseptic meningitis.
INACTIVE ISSUES
# Cardiology - continued home simvastatin 20mg qd
#Hematology - Anemic, at baseline, this remained stable.
# Pulm - continued home spiriva
# Renal: CKD ___ RPGN, baseline Cr 1.9. Given IVF and creatinine
monitored while on acyclovir, it remained at baseline. Continued
home dose calcium acetate for low Ca and phosphate.
# Endo - continued home levothyroxine
OUTSTANDING ISSUES
- F/U arbovirus
- Has neurology follow up to monitor for resolution of symptoms |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naltrexone
Attending: ___
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
this patient is a ___ yo M w/ ___ year h/o alcohol abuse that
presents to ED with alcohol withdrawal. Has been drinking at
least 2 pints of vodka/day for several years and has attempted
to quit multiple times. Last attempt to quit was 2 weeks ago,
but started again 4 days ago to combat withdrawal symptoms. He
stopped again 2 days later, but now was withdrawal symptoms
"much worse than before". These include N/V, diaphoresis,
diffuse body aches, tremor and chills. Last drink was several
hours prior to ED admit in order to stop symptoms. Reports
history of withdrawal seizure in the past, and felt like he was
"on the verge" of a seizure this time. Reports gradually
worsening dry cough, SOB, DOE, PND, and orthopnea over the last
several months. Denies diarrhea, abdominal pain, chest pain,
palpitations, weight loss, wheeze, or dysuria. Does not wish to
go to ___ rehab facility and wants to leave. Is a member
of AA.
Past Medical History:
alcohol abuse
seizure secondary to EtOH withdrawal
benign hypertension
GERD
depression
Social History:
___
Family History:
Father-DM
Brother-MI
Physical Exam:
Admission Exam:
Vitals: T: 98.7, BP: 146/98, P: 106, R: 16, O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, + distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non focal
.
Discharge Exam:
VS 98.1 ___ 96%RA
GEN Alert, orientedx3, mild distress
HEENT NCAT, Dry MM, EOMI, Pupils 3-4mm and reactive, sclera
anicteric, OP clear
NECK no JVD, no LAD
PULM CTAB no wheezes, rales, ronchi. Good air flow
CV Tachycardic. Regular rate. normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal, no tremor
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 05:20PM BLOOD WBC-5.1 RBC-4.37* Hgb-15.6 Hct-46.5
MCV-106* MCH-35.7* MCHC-33.5 RDW-12.9 Plt Ct-88*
___ 05:20PM BLOOD Plt Smr-LOW Plt Ct-88*
___ 05:20PM BLOOD Glucose-244* UreaN-12 Creat-1.0 Na-142
K-3.3 Cl-100 HCO3-23 AnGap-22*
___ 05:20PM BLOOD ALT-117* AST-146* AlkPhos-73 TotBili-0.6
.
Discharge Labs:
___ 06:05AM BLOOD WBC-5.1 RBC-3.86* Hgb-14.1 Hct-42.1
MCV-109* MCH-36.7* MCHC-33.6 RDW-13.0 Plt Ct-72*
___ 06:05AM BLOOD Glucose-113* UreaN-10 Creat-0.8 Na-140
K-3.7 Cl-99 HCO3-35* AnGap-10
___ 06:05AM BLOOD ALT-94* AST-87* LD(LDH)-207 AlkPhos-57
TotBili-0.9
___ 06:05AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.5*
.
Studies:
CXR: No acute cardiopulmonary process.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Alcohol abuse, alcohol withdrawal
SECONDARY: Macrocytosis
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.
___.
FINDINGS: PA and lateral chest radiographs demonstrate no focal
consolidation, pleural effusion, or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WITHDRAWAL
Diagnosed with ALCOHOL WITHDRAWAL, ALCOH DEP NEC/NOS-CONTIN
temperature: 97.7
heartrate: 116.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 75.0
level of pain: 8
level of acuity: 3.0 | ___ yo M w/PMH significant for EtOH abuse for the last ___ years
that presents with EtOH withdrawal after abstaining for the last
4 days. Did not wish to go to ___ rehab facility. As the
patient had no desire to quit alcohol, he was discharged after
scoring <10 on CIWA during day following admission.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking female, h/o GIST on low dose sudent, DM,
diastolic CHF, PAF, not on AC, presenting with hypoxia. Her ___
found her to be hypoxic to the 70's associated with dyspnea. She
says the shortness of breath at rest started yesterday and is
associated with increased orthopnea and PND over the last 2
nights. She denies recent fevers, chills, or cough. Denies chest
pain, pleuritic or otherwise. She notes no dietary indiscretion.
Today, her ___ noted her to be hypoxic on RA and called EMS, who
found her to be in the ___ on 4L NC.
.
Of note, she was recently restarted on low dose of sudent for
GIST. Sudent had been on hold due to chronic right leg lesion
that developed following a punch biopsy a rash on her leg in
___. She was also recently hospitalized for decreased
hematocrit and received 1 unit pRBC. During that admission, she
was found to have decompensation of dCHF and which reponded well
to diuresis with IV lasix.
.
In the ED, initial VS: 98.6 102 142/67 20 87%. CXR noted
pulmonary edema, bilateral pleural effusions, and cardiomegaly
c/w CHF. Her Cr was 1.2 and BNP was 2824. She was given 1 SL NTG
and 40 IV lasix. Oncologist was called and advised stopping
Sudent during hospitalization. VS prior to transfer: 138/81, 92
afib, ___, RR 20, temp 98.4.
.
Currently, patient is comfortable on 2L, and requesting food.
.
ROS: Notable as above and for recent constipation. Otherwise
limited ROS negative for HA, fevers, chills, NVD, new rashes.
Past Medical History:
- RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late ___ and underwent a biopsy of the area
___. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on ___.
- GIST: Diagnosed in ___, treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in ___, and a
GIST omental metastasis resection in ___. Noted to have GIB
in ___ and ___ due to enlarging GIST lesions. Started
on Sutent since ___. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in ___, Residual R hemiparesis and intermittent aphasia,
- TIA in ___
- Status post knee surgery in ___.
Social History:
___
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
ON ADMISSION:
VS - Temp 98.2F, BP 153/87 , HR 96 , R 20 , O2-sat 98% 2L
GENERAL - well-appearing obese woman in NAD, comfortable,
appropriate. ___ speaking.
HEENT - PERRL, EOMI, sclerae anicteric, Dry MM, OP clear
NECK - supple, JVD difficult to appreciate
LUNGS - Mild expiratory wheeze, otherwise CTAB. Fair movement,
resp mildly labored with exertion
HEART - RRR, no MRG, nl S1-S2. No S3 appreciated
ABDOMEN - Obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - approx 7x0.25 cm healing wound with edges approximating
over rt medial thigh. Appears healthy. Dressing c/d/i.
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact to FTN
ON DISCHARGE:
Weight: 92.5 kg (from 93 kg yesterday)
Is&Os:
Yesterday - 1260/1590
First eight hours of today - ___
VS - Temp 97.6 F, BP 138/90 (120s-130s/60s-90s) HR 79 (70s -
90s), R 20, O2-sat 95% on RA
GENERAL - well-appearing obese woman in NAD, comfortable,
appropriate.
HEENT - sclerae anicteric, moist mucus membranes.
NECK - supple, JVD difficult to appreciate
LUNGS - Breathing non-labored. Very few bibasilar crackles, no
wheezes, no rhonchi
HEART - RRR, no MRG, nl S1-S2. No S3 appreciated
ABDOMEN - Obese, NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, 1+ lower extremity edema to mid-calf.
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 01:10PM GLUCOSE-153* UREA N-25* CREAT-1.2* SODIUM-142
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 01:10PM cTropnT-<0.01
___ 01:10PM proBNP-2824*
___ 01:10PM WBC-6.0 RBC-2.81* HGB-8.6* HCT-28.5* MCV-101*
MCH-30.6 MCHC-30.2* RDW-17.0*
___ 01:10PM NEUTS-81.0* LYMPHS-13.7* MONOS-4.0 EOS-0.9
BASOS-0.5
___ 01:10PM ___ PTT-30.1 ___
___ 01:18PM LACTATE-1.7 K+-3.8
___ 09:29PM CK-MB-2 cTropnT-<0.01
___ 09:29PM CK(CPK)-51
___ 10:14PM URINE MUCOUS-RARE
___ 10:14PM URINE RBC-1 WBC-22* BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 10:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-MOD
___ 10:14PM URINE COLOR-Yellow APPEAR-Clear SP ___
STUDIES:
CXR: prelim: Moderate pulmonary edema and small bilateral
pleural effusions and cardiomegaly consistent with congestive
heart failure.
Discharge labs:
___ 09:30AM BLOOD WBC-4.9 RBC-2.98* Hgb-9.5* Hct-30.9*
MCV-104* MCH-31.9 MCHC-30.8* RDW-17.0* Plt ___
___ 09:30AM BLOOD Glucose-203* UreaN-26* Creat-1.1 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-14
___ 06:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:29PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:10PM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
___ 10:14 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
1. furosemide 40 mg DAILY
2. levothyroxine 200 mcg DAILY
3. timolol maleate 0.5 % One Drop DAILY
4. diltiazem HCl 180 mg DAILY
5. zolpidem 10 mg PO HS as needed for insomnia.
6. oxycodone 5 mg PO once a day as needed for pain
7. senna prn
8. Januvia 100 mg once a day.
9. docusate sodium prn
10. ASA 81
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic once
a day.
4. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for Pain.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Acute on chronic diastolic CHF exacerbation.
Hypertension.
SECONDARY: Gastro-intestinal stromal tumor.
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 or CHF.
COMPARISON: CT abdomen and pelvis on ___ and chest radiograph on
___.
FINDINGS: AP portable erect AP view of the chest. Diffuse bilateral mainly
basilar parenchymal opacities consistent with moderate pulmonary edema. Small
bilateral pleural effusions. Cardiomegaly is stable. Mediastinum is still
slightly widened due to mediastinal venous engorgement.
IMPRESSION: Moderate pulmonary edema and small bilateral pleural effusions
and cardiomegaly consistent with congestive heart failure.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: DYSPNEA/HYPOXIA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, RESPIRATORY ABNORM NEC, HYPOXEMIA
temperature: 98.6
heartrate: 102.0
resprate: 20.0
o2sat: 87.0
sbp: 142.0
dbp: 67.0
level of pain: 0
level of acuity: 1.0 | ASSESSMENT & PLAN: ___ yo ___ speaking female, h/o GIST on
low dose sutent, DM, diastolic CHF, PAF, not on AC, presenting
with likely CHF exacerbation.
ACTIVE ISSUES:
1. Acute on Chronic Diastolic Congestive Heart Failure
exacerbation: Suspect due to ___ exacerbation given CXR
findings, symptoms of orthopnea and PND, and response to 40IV
lasix in ED. Etiology of CHF exacerbation was unclear.
Infectious process was not identified. Patient was ruled out
for myocardial infarction. It is possible that she was
hypertensive (possibly as a side effect of sutent) and this led
to worsening diastolic CHF.
Patient received lasix 40 mg IV x1 with excellent response. On
the first day of admission, she was weaned off oxygen
completely. She was restarted on her home dose of lasix 40 mg
PO daily. Her blood pressure was controlled with her home dose
of diltiazem and systolic blood pressure ranged 120 - 130 on the
day of admission.
# GIST: Patient with hx of GIST s/p incomplete resection in ___
and omental resections in ___. Intermittently treated with
gleevac complicated by side effects, now on low dose sutent. The
sutent was held during hospitalization and she will restart it
at home as discussed with the oncology fellow. She has ___
following her and they will check her blood pressure on ___.
# ARF: Cr mildly above baseline to 1.2 on admission. Likely due
to CHF. Improved to 1.1 with diuresis on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of hypertension, PE, severe
necrotizing pancreatitis thought likely secondary to gallstones
with multiple complications including infection, acute
cholecystitis, and distal biliary stricture who is presenting
with fevers.
Started having fevers yesterday afternoon, 101.4F. Had not had
fevers before that. Had chills. No headache, vision changes or
neck stiffness. No shortness of breath or coughing. No abdominal
pain, no diarrhea. No urinary symptoms. No coldlike symptoms.
Two
nights before, his hands were very itchy. Yesterday, itchiness
worsened including feet, hands, legs, arms, body. His wife told
him to ___ the ED and so he went. He went to ___ ED.
In ___, redness, swelling, and drainage made his PCP
concerned for ___ soft tissue infection. Was prescribed Keflex for
10 days, resolved. In ___, same symptoms came back, was
represcribed Keflex for 10 days. Despite 10 days of it, the
symptoms worsened. Went back to PCP's office, and prescribed
levofloxacin. Took that for about ___ days when he was called by
his PCP that he had MRSA and was prescribed Bactrim instead.
Started taking Bactrim on ___. Since then, has taken Bactrim
everyday until yesterday morning. He also went to ___ given
concern for drain infection, at which point, he had both of his
drains replaced on ___. Of note, the cholecystostomy tube was
found to be dislodged from the gallbladder and was successfully
reinserted. A contrast study into the gallbladder demonstrated
a
fistula to the duodenum.
He states that his drain site looked angry, red, raised, and
painful until he started taking the Bactrim (prescription sent
in
on ___ and started taking on ___. Since then, he states
that it has improved significantly and almost feels back to
normal. He confirms he never had fevers until after he started
taking the Bactrim.
The day before on ___ he was started on Bactrim. Since then,
he has had good output from his drains with serous segment is
fluid from the transhepatic catheter and bilious discharge from
the cholecystotomy tube. He denies any acute pain at the
insertion sites. He has developed a erythematous, blanching,
maculopapular rash that is diffuse and extremely pruritic. He
has
tried several doses of Benadryl with little relief. He is also
been associated with chills and a temp max of 101.4 that
responded well to Tylenol. He has no other associated symptoms
and denies any headache, vision changes, URI symptoms, cough,
chest pain, dyspnea, abdominal pain, nausea, vomiting, diarrhea,
UTI symptoms, changes in urination color or stool color. He
denies any sick contacts or anyone else with the same rash. He
has not been outside the country recently.
Past Medical History:
Hypertension
Social History:
___
Family History:
Mother had DM, breast cancer. Father had HTN, MI in ___.
Physical Exam:
ADMISSION EXAM:
==============
Vitals: reviewed in omr
General: alert and oriented x3, pleasant mood and affect
HEENT: PERRL, EOMI
Neck: supple
Lungs: CTAB
CV: rrr, normal s1 and s2, no s3 or s4, no murmurs, gallops, or
rubs
GI: nontender, nondistended, bowel sounds present
Ext: no edema noted, no cyanosis
Neuro: moving all extremities with purpose and against gravity
Skin: unable to identify the diffuse maculopapular rash noted
by
the ED
DISCHARGE EXAM:
===============
GEN: NAD, resting comfortably
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2, no M/R/G
PULM: no respiratory distress, CTAB, no W/R/R
ABD: soft, Non-tender, Non-distended, no rebound or guarding, no
mass, no hernia, biliary drainage tubes x2 with bilious output
EXT: warm, well-perfused, no edema
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal insight, memory, mood/affect
Pertinent Results:
ADMISSION LABS:
=============
___ 11:18PM BLOOD WBC-7.7 RBC-4.30* Hgb-11.9* Hct-36.4*
MCV-85 MCH-27.7 MCHC-32.7 RDW-13.1 RDWSD-40.4 Plt ___
___ 11:18PM BLOOD Neuts-79.9* Lymphs-9.4* Monos-5.2 Eos-5.2
Baso-0.0 Im ___ AbsNeut-6.14* AbsLymp-0.72* AbsMono-0.40
AbsEos-0.40 AbsBaso-0.00*
___ 11:48PM BLOOD ___ PTT-29.6 ___
___ 11:18PM BLOOD Glucose-126* UreaN-30* Creat-1.9* Na-134*
K-4.4 Cl-99 HCO3-19* AnGap-16
___ 11:18PM BLOOD ALT-32 AST-36 AlkPhos-172* TotBili-0.2
PERTINENT STUDIES:
================
LIVER OR GALLBLADDER US
1. Normal sonographic appearance of the hepatic parenchyma
without focal
lesion.
2. PTBD coursing through the CBD area with distal portion
obscured by bowel
gas.
3. Percutaneous cholecystostomy tube is not well visualized due
to overlying
bowel gas and bandage.
DISCHARGE LABS:
==============
___ 07:00AM BLOOD WBC-5.4 RBC-4.49* Hgb-12.2* Hct-38.1*
MCV-85 MCH-27.2 MCHC-32.0 RDW-13.3 RDWSD-41.4 Plt ___
___ 07:00AM BLOOD Neuts-48.3 ___ Monos-13.1*
Eos-11.1* Baso-0.2 Im ___ AbsNeut-2.61 AbsLymp-1.45
AbsMono-0.71 AbsEos-0.60* AbsBaso-0.01
___ 07:00AM BLOOD ___ PTT-29.0 ___
___ 07:00AM BLOOD Glucose-102* UreaN-22* Creat-1.3* Na-139
K-5.0 Cl-101 HCO3-25 AnGap-13
___ 07:00AM BLOOD ALT-32 AST-26 AlkPhos-150* TotBili-0.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO BID
2. TraZODone 50 mg PO QHS:PRN insomnia
3. Pantoprazole 40 mg PO Q12H
4. Ondansetron 8 mg PO Frequency is Unknown
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Every twelve
hours Disp #*10 Tablet Refills:*0
2. Ondansetron 8 mg PO Q8H:PRN Nausea
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. Labetalol 100 mg PO BID
6. Pantoprazole 40 mg PO Q12H
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute drug reaction
Cellulitis
SECONDARY DIAGNOSIS:
====================
History of necrotizing pancreatitis
Common bile duct stricture
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) PORT
INDICATION: History: ___ with pruritic rash after re-exchange of catheter//
eval for placement of catheter and liver
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CTA abdomen pelvis ___. Fluoroscopic images from ___ BD
exchange and cholecystostomy tube placement ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites. A catheter is seen coursing
through the CBD area consistent with the PTBD. However, the distal portion of
the PTBD is obscured by bowel gas. The percutaneous cholecystostomy tube is
not well visualized due to overlying bowel gas and bandage.
BILE DUCTS: There is no intrahepatic biliary dilation.
CBD: 10 mm
GALLBLADDER: The gallbladder is not well visualized due to overlying bowel gas
and bandage.
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 right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal sonographic appearance of the hepatic parenchyma without focal
lesion.
2. PTBD coursing through the CBD area with distal portion obscured by bowel
gas.
3. Percutaneous cholecystostomy tube is not well visualized due to overlying
bowel gas and bandage.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with rising Cr, unclear etiology. Evaluation for
evidence of hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Comparison to CTA abdomen/pelvis from ___.
FINDINGS:
The right kidney measures 10.1 cm. The left kidney measures 11.2 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is only minimally distended and can not be fully assessed on the
current study.
IMPRESSION:
Normal renal ultrasound without evidence of stones or hydronephrosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified, Acute kidney failure, unspecified, Gen skin eruption due to drugs and meds taken internally, Adverse effect of sulfonamides, initial encounter, Oth places as the place of occurrence of the external cause
temperature: 98.9
heartrate: 86.0
resprate: 18.0
o2sat: 99.0
sbp: 117.0
dbp: 67.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of gallstone
pancreatitis c/b necrotizing pancreatitis,
perihepatic/peripancreatic fluid collections, CBD stricture s/p
PTBD and cholecystostomy tube placement, HTN, h/o PE and SMV
thrombus, who
#Acute drug reaction: The patient had a fever on ___ of 101.3.
For the past month, patient had a complicated antibiotic course
(Keflex in ___ for 2 10 day courses, Levofloxacin, and
finally Bactrim starting ___ given MRSA cellulitis,
discussed below.) In the ED, the patient was noted to have a
fever and a rash. His biliary drain sites looked clean without
any active signs of infection, and his lab work did not show any
underlying infection. This is though to have been a reaction to
Bactrim, and the patient was taken off of Bactrim with
improvement in his rash, and was afebrile during his
hospitalization. Bactrim was added to his allergy list.
#MRSA Cellulitis: The patient was diagnosed with cellulitis in
___ and was initially treated with Keflex, then Levaquin,
then ultimately Bactrim as above when his cultures grew MRSA.
Bactrim was started on ___. His exam did not show any
erythema around his catheter site, nor did it show any exudate
or signs of underlying infection indicating a resolving
cellulitis. Given his allergy to Bactrim, he was started on IV
Vancomycin on admission for MRSA coverage, but was ultimately
changed to PO Doxycycline 100 mg PO Q12H to complete a 10 day
course on ___.
___: Baseline in ___ was 1. Cr on ___ 1.5. Cr on admission
1.9. Renal US showing no evidence of hydronephrosis, and no
clear indication of post renal pathology. Has been taking good
PO lately, and did not appear dry so low concern for pre-renal.
Most likely ___ secondary to Bactrim, which can also raise serum
Cr, though may not reflect true decrease in Cr clearance. Cr
improved to 1.3 with removal of Bactrim, and the patient was
discharged with Cr. 1.3.
#Upcoming R&Y hepaticojejunostomy: Procedure delayed in the past
for cellulitis as described above. Has upcoming CCY and R&Y
hepaticojejunostomy which was rescheduled to ___. However,
given the patient's continued soft tissue infection, ___ and
drug reaction as described above, the patient's procedure was
again delayed per his surgery team until resolution of his
underlying infection. He was discharged with follow up with Dr.
___ his surgical team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with medical history of
esophageal strictures s/p dilation, GERD, low back pain, chronic
venous insufficiency, and BPH, who presents with several days of
epigastric pain. He states that he was at his baseline state of
health until "a couple days" prior to presentation when he was
rushing to eat his boiled eggs before the start of a baseball
game, and swallowed too large of a piece of egg, reporting that
he "overdid it." He notes that after eating he had acute onset
epigastric pain which was a ___ in severity, nonradiating,
and constant. The pain has persisted in the subsequent days
despite the patient's efforts to take smaller bites and chew
thoroughly. He notes that the pain is exacerbated by swallowing
and by his chronic cough of several months duration which is
productive of a thin, white, non-bloody sputum. He notes that
the pain is somewhat relieved with the pain medications received
in the ED. Of note, the patient describes that since his
stricture dilation procedure, he has been warned that he cannot
take too large of bites and is usually cautious to chew
thoroughly before swallowing; he typically tries to follow these
recommendations, but did not on this occasion. He presented to
the ED by ambulance from the ___ today because of the
persistence of this pain.
He denies any associated fever, chills, chest pain, dysuria,
nausea, vomiting, or diarrhea.
In the ED, initial vitals: Temp 98.1 HR 64 BP 157/50 RR 20 O2
98% RA.
- Exam notable for: Pt A&Ox3, speaking in full coherent
sentences, taking nonlabored breaths with equal chest rise, no
SOB or cough. Abdomen soft, nontender.
- Labs notable for: H/H 12.1/36.6 (above recent baseline of 11),
WBC 12 (72.8% PMNs), chemistries notable for BUN 33, Cr 1.7
(most recent baseline of 1.1 in ___. He had an unremarkable
liver panel and troponins <0.01, proBNP WNL and normal lactate.
UA was notable for large leukocytes, WBCs >182, negative for
nitrites.
- Imaging notable for: CT abdomen pelvis w/o contrast with large
hiatal hernia, pancolonic diverticulosis without active
inflammation, and no acute findings.
- Pt given: 1L NS and 1g IV CTX. Blood cx's were sent. He was
admitted to medicine for management of UTI and presumed ___.
- Vitals prior to transfer: Temp 98.5 HR 80 BP 153/62 RR 18 O2
96% RA.
On arrival to the floor, pt reports improvement of his pain.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No nausea or vomiting. No diarrhea or constipation. No dysuria
or hematuria. No hematochezia, no melena. No numbness or
weakness, no focal deficits.
Past Medical History:
esophageal strictures
esophagitis
GERD
sinus bradycardia
Mobitz Type 1, asymptomatic
Chronic venous insufficiency
BPH
Low back pain
asthma
glaucoma
cataracts
venous stasis ulcer
hypertension
Tonsillectomy
esophageal stricture dilation (___)
hernia repair
testicular surgery of some sort
cataract surgery
Social History:
___
Family History:
hypertension, no history of prostate cancer. His children are
healthy
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.8 133/57 69 20 99% on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear, R eye with
strabismus/disconjugate gaze
Neck- supple, JVP elevated to earlobe, no LAD
Lungs- CTAB without rales or rhonchi
CV- RRR, Nl S1/S2 w/S3 and early systolic murmur
Abdomen- obese, soft, bowel sounds present, suprapubic
tenderness to deep palpation without rebound tenderness or
guarding. No CVA tenderness.
GU- no foley, extensive hyperpigmented, scaly plaques from the
gluteal cleft to the groin and along the trigone region.
Ext- feet slightly cool to touch bilaterally, with thickened,
leathery skin consistent with venous stasis, pulses faintly
palpable, no clubbing or cyanosis, pitting edema bilaterally L>R
Neuro- CN ___ intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
Vitals: 99.8 104/49-145/40 56-100 ___ 100% on RA
Weight: 84.6 kg
Exam:
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear, R eye with
strabismus/disconjugate gaze
Neck- supple, JVP elevated to earlobe, no LAD
Lungs- CTAB without rales or rhonchi
CV- RRR, Nl S1/S2 w/S3 and early systolic murmur
Abdomen- obese, soft, bowel sounds present, nontender, no
rebound tenderness or guarding. No CVA tenderness.
GU- no foley, extensive hyperpigmented, scaly plaques from the
gluteal cleft to the groin and along the trigone region.
Ext- feet slightly cool to touch bilaterally, with thickened,
leathery skin consistent with venous stasis, pulses faintly
palpable, no clubbing or cyanosis, pitting edema bilaterally L>R
Neuro- CN ___ intact, motor function grossly normal
Pertinent Results:
LABS ON ADMISSION
___ 11:42PM URINE RBC-4* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-<1
___ 11:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 11:42PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:05AM PLT COUNT-213
___ 12:05AM NEUTS-72.8* LYMPHS-17.9* MONOS-6.9 EOS-1.7
BASOS-0.2 IM ___ AbsNeut-8.73* AbsLymp-2.14 AbsMono-0.83*
AbsEos-0.20 AbsBaso-0.02
___ 12:05AM WBC-12.0* RBC-4.40* HGB-12.1* HCT-36.6*
MCV-83 MCH-27.5 MCHC-33.1 RDW-17.0* RDWSD-51.1*
___ 12:05AM ALBUMIN-3.8
___ 12:05AM cTropnT-<0.01 proBNP-240
___ 12:05AM LIPASE-42
___ 12:05AM ALT(SGPT)-14 AST(SGOT)-29 ALK PHOS-44 TOT
BILI-0.4
___ 12:05AM estGFR-Using this
___ 12:05AM GLUCOSE-101* UREA N-33* CREAT-1.7* SODIUM-137
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
MICRO DATA
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
LABS ON DISCHARGE
___ 06:42AM BLOOD WBC-6.4 RBC-4.40* Hgb-12.0* Hct-37.1*
MCV-84 MCH-27.3 MCHC-32.3 RDW-16.9* RDWSD-52.1* Plt ___
___ 06:42AM BLOOD Glucose-74 UreaN-24* Creat-1.4* Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
___ 06:42AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.2
IMAGING
___ CXR: Large hiatal hernia. Moderate bibasilar
atelectasis.
___ CT ABD & PELVIS W/O CONTRAST:
1. Large hiatal hernia.
2. Pancolonic diverticulosis without active inflammation.
3. Old compression deformity of the L1 vertebral body.
4. No acute findings.
___ BARIUM SWALLOW:
1. Mild narrowing of a short segment of the upper esophagus.
2. Ulcerations of the distal esophagus which can be further
evaluated with endoscopy.
3. Moderate-large hiatal hernia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Senna 8.6 mg PO QHS
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Omeprazole 20 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Travatan Z (travoprost) 0.004 % ophthalmic daily
9. LOPERamide 2 mg PO TID:PRN constipation
10. Guaifenesin ___ mL PO Q6H:PRN cough
11. Acetaminophen 500 mg PO Q8H:PRN pain
12. ammonium lactate 12 % topical PRN lower extremities
13. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
14. Sarna Lotion 1 Appl TP BID b/l leg itch
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Chlorthalidone 25 mg PO DAILY
5. Guaifenesin ___ mL PO Q6H:PRN cough
6. LOPERamide 2 mg PO TID:PRN constipation
7. Omeprazole 20 mg PO BID
8. Senna 8.6 mg PO QHS
9. Tamsulosin 0.4 mg PO QHS
10. Travatan Z (travoprost) 0.004 % ophthalmic daily
11. Vitamin D 1000 UNIT PO DAILY
12. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
13. ammonium lactate 12 % topical PRN lower extremities
14. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
15. Sarna Lotion 1 Appl TP BID b/l leg itch
16. rolling walker
Dx: dysphagia 787.2
Px: good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
hiatal hernia
esophageal ulceration
upper esophageal stricturing
SECONDARY DIAGNOSIS
esophageal strictures
GERD
Chronic venous insufficiency
BPH
Low back pain
asthma
hypertension
hernia repair
cataract surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with several days of epigastric pain and productive
cough // evaluate for heart filure
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT from ___
FINDINGS:
There is a moderate hiatal hernia. Heart size is enlarged. Mild central
vascular prominence. No interstitial edema. Moderate bibasilar atelectasis.
No pleural effusions.
IMPRESSION:
Large hiatal hernia. Moderate bibasilar atelectasis.
Radiology Report
INDICATION: ___ male with abdominal pain.
TECHNIQUE: CTU: Multidetector CT images of the abdomen and pelvis were
acquired without intravenous contrast administration with the patient in
supine position with low radiation dose technique. 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: 800 mGy-cm (abdomen and pelvis).
COMPARISON: CT abdomen from ___ and CT chest from ___
FINDINGS:
LOWER CHEST: Imaged lung bases demonstrate considerable bibasilar atelectasis
and no consolidation. Heart is mildly enlarged with no pericardial effusion.
There is a large hiatal hernia.
ABDOMEN:
Evaluation of the intra-abdominal solid organs is limited by lack of
intravenous contrast. The liver, gallbladder, and pancreas are normal.
Spleen demonstrates multiple granulomas, from prior granulomatous infection.
The adrenal glands are normal bilaterally. The kidneys are normal in size
with no hydronephrosis or stones.
There is a large hiatal hernia. Small bowel is normal in caliber without
obstruction. The appendix is air-filled with no surrounding inflammation.
There is pan colonic diverticulosis, without evidence of active inflammation.
No mesenteric or retroperitoneal lymphadenopathy. No free air or free fluid.
VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium
burden in the abdominal aorta and great abdominal arteries.
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: Prostate is mildly enlarged.
BONES AND SOFT TISSUES: There is mild osseous demineralization and an
unchanged compression deformity of the L1 vertebral body compared to ___. Degenerative changes of the lower lumbar spine are moderate and
unchanged. No evidence of acute fracture.
IMPRESSION:
1. Large hiatal hernia.
2. Pancolonic diverticulosis without active inflammation.
3. Old compression deformity of the L1 vertebral body.
4. No acute findings.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man with history of esophageal stricture now
presenting with epigastric pain in the setting of swallowing and coughing.
Please assess for esophageal stricture or food impaction
TECHNIQUE: Barium esophagram.
COMPARISON: Chest CT from ___
FINDINGS:
The esophagus was not dilated. There was a segment of mild narrowing in the
upper esophagus. There was no esophageal mass. Irregularity of the distal
esophagus wall reflects ulcers/ulceration.
The primary peristaltic wave was normal, with contrast passing readily into
the stomach. A large hiatal hernia is again noted, similar to prior CT.
No overt abnormality in the stomach or duodenum on limited evaluation.
IMPRESSION:
1. Mild narrowing of a short segment of the upper esophagus.
2. Ulcerations of the distal esophagus which can be further evaluated with
endoscopy.
3. Moderate-large hiatal hernia.
Gender: M
Race: SOUTH AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with URIN TRACT INFECTION NOS
temperature: 98.1
heartrate: 64.0
resprate: 20.0
o2sat: 98.0
sbp: 157.0
dbp: 50.0
level of pain: 8
level of acuity: 2.0 | #EPIGASTRIC PAIN: admitted with acute onset of epigastric pain
after eating a large piece of food, which persisted for several
days and was exacerbated by swallowing and coughing. Initial
chemistries and Lipase were within normal limits. CT showed
hiatal hernia, pancolonic diverticulosis without inflammation
and no evidence of acute abdominal pathology. Blood cultures
were negative to date, finalization pending at the time of
discharge. He was thoroughly worked up for a cardiac etiology
with CXR, EKG, and troponins which were all negative for an
acute cardiac cause. Given the patient's history of tandem
esophageal strictures with dilation in ___, gastroenterology
was consulted. They advised that it was very likely that the
patient's esophageal strictures have narrowed since his
dilation; however when he is compliant with his diet and chews
well he does not seem to have any problems with swallowing. He
underwent a barium swallow study which showed narrowing at the
upper esophagus and ulcerations at the GEJ near his large hiatal
hernia. Because this was not preventing the patient from eating
or staying hydrated, gastroenterology recommended Mr. ___ be
evaluated further with an EGD, in the outpatient setting. He
will follow up with his outpatient gastroenterologist Dr. ___
on ___ at 11:45AM. Mr. ___ reported improvement
in his pain over the course of his hospitalization, and was
tolerating a regular diet at the time of discharge. He was
continued on his home omeprazole 20mg BID.
#UTI: During his hospitalization, also noted to have
leukocytosis, suprapubic tenderness and a concerning UA He was
given 2L of fluids, and treated with ceftriaxone and
transitioned to cefpedoxime to complete a treatment course for
complicated UTI (start date ___, end date ___. Leukocytosis
resolved and patient remained afebrile.
#BRADYCARDIA: the patient experienced chest palpitations and had
several episodes of bradycardia into the ___ which occurred
specifically overnight while sleeping. Cardiology was consulted
due to concern for potential heart block, as EKG was suggestive
of Mobitz I. Cardiology suggested Mr. ___ ECG abnormalities
were likely Mobitz Type I in the setting of increased vagal tone
overnight. Cardiology commented that on ECG, there was evidence
of dual AV nodal pathway, as reflected in the nodal echo after
select QRS complexes that precede dropped p waves. Overnight
telemetry was reviewed and was notable for of 2:1 heart block,
and given the increased vagal tone during sleep, they suggested
this was likely Mobitz Type I. Cardiology notes that the 2:1
block dissipates when the patient is awake and vagal tone is
suppressed. Given that the patient was subsequently asymptomatic
and was hemodynamically stable throughout, cardiology
recommended that he did NOT need a pacemaker or pharmacologic
intervention at this time. They also recommended that should the
patient have episodes of heart block while awake, ambulating
telemetry can be considered; AV nodal agents should be avoided.
The patient was advised to follow-up with his cardiologist
should he develop any new symptoms, including palpitations,
lightheadedness, shortness of breath, near-syncope and syncope.
#TINEA CRURIS: The patient was noted to have significant
perineal itching with scaly hyper- and hypopigmented plaques
consistent with tinea cruris. He was started on an antifungal
cream, but would benefit from follow-up to ensure resolution.
#Weakness: Patient presenting from nursing home, unsteady on
feet. ___ was consulted; they recommended additional inpatient ___
and discharge with home ___ as well as use of a walker upon
discharge back to the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia, neutropenia, nausea, lack of appetite, weight loss and
productive cough
Major Surgical or Invasive Procedure:
___ MRCP
___ ERCP CBD stent removed
___ R arm PICC placed
___ 2 PTBDs exchanged and pigtail exchanged
History of Present Illness:
___ year old male well known to our service
for his DDLT on ___ currently maintained on cyclosporine
and MMF. His postoperative course has been complicated by
hepatic
arterial thrombosis from a hypercoagulable acquired state, left
lobe liver infarct, stricturing of the right anterior and
posterior biliary system and bilateral liver infected bilomas
with VRE which have been treated with placement of PTBD drainage
and IV antibiotic therapy from mid ___ till ___
under the direction of ID. The antibiotics were transitioned to
PO linezolid on ___. The patient is being assessed by
transplant surgery for pancytopenia and associated 1 week of
progressive loss of appetite and weight associated with
generalized weakness.
He was last time seen in our clinic by Dr. ___ on ___.
At
that time he had remained afebrile and follow up CT imaging of
abdomen from ___ demonstrated interval improvement of the
biliary dilatation, decreased size of collection near the
posterior ductal confluence and interval decrease in size of the
large left liver lobe collection.
As above, he comes to the ED with complains of unable to eat
given constant nausea, lack of appetite, weight loss and
productive cough. He endorses bringing up white plegm. He had an
episode of a "temp greater than 100". Denies GI bleeding,
chills,
diarrhea, abdominal pain, obstipation, muscle aches, mucosal
bleeding/petechial rash. Upon exam, VS: 98.6, 90, 119/69, 17,
100% room air. Exam notable unremarkable. Generalized jaundice.
Abdomen benign. Non-distended, non-tender, non-distended. PTBD
in
place to gravity. Murky output and per patient the
characteristics are unchanged. Labs remarkable for stable Tbil
at
3.0 and interval decrease in AST (46->17) ALT (50->21) and
alphos
(1144 ->945)since last examined on ___. White count low to
1.0 from 5.8 when last examined. Hct low to 18.8 from 31.0.
Slight increased in creatinine to 1.6 from 1.0.
ROS:
(+) per HPI
(-) Denies pain, chills, night sweats, pruritis, jaundice,
rashes, bleeding, easy bruising, headache, dizziness, vertigo,
syncope, weakness, paresthesias, vomiting, hematemesis,
bloating,
cramping, melena, BRBPR, dysphagia, chest pain, shortness of
breath, cough, edema, urinary frequency, urgency
Past Medical History:
Past medical history:
- EtOH cirrhosis s/p TIPS ___
- ___ s/p RFA x2 ___ & ___
- skin cancer
Past surgical history:
- DDLT (___)
- Re-exploration of DDLT, pexy of right hemidiaphragm
(___)
- Pericardial window via left anterior thoracotomy (___)
Social History:
___
Family History:
Family History:
- father died of cancer, patient is not sure what type
Physical Exam:
Vitals signs: T 98.6 BP 126/81 HR 72 RR 18 O2Sat 96
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
right abdomen PTB drains capped, with a CDI access site. Midline
abdomen pigtail drain to bag.
Incision well healed.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Labs on Admission: ___
WBC-1.0* RBC-2.30* Hgb-5.5* Hct-18.8* MCV-82 MCH-23.9*
MCHC-29.3* RDW-15.2 RDWSD-45.7 Plt Ct-92*
___ PTT-39.1* ___
Glucose-136* UreaN-49* Creat-1.6* Na-134* K-5.3* Cl-97 HCO3-22
AnGap-15
ALT-17 AST-21 AlkPhos-945* TotBili-3.0*
Albumin-2.6*
Calcium-8.2* Phos-3.8 Mg-1.8
Digoxin-1.9*
Cyclspr-238
BLOOD CMV VL-NOT DETECT
EBV DNA, QN PCR <200 Normal <200 copies/mL
.
Imaging:
1. Markedly heterogeneous liver parenchyma with areas of
intraparenchymal gas, most notable in the left lobe which
correlate with prior areas of abscesses
better seen in the ___ CT abdomen and pelvis.
2. Partially visualized drainage catheters as described above.
3. Please note that visualization of the lung parenchyma is
limited by overlying bandages.
4. 17.9 cm splenomegaly.
5. Patent hepatic vasculature with appropriate waveforms;
persistent low hepatic artery resistive indices measuring
0.42-0.55, previously 0.43.
___ 06:00AM BLOOD WBC-5.6 RBC-2.74* Hgb-7.8* Hct-24.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-17.4* RDWSD-56.7* Plt ___
___ 06:30AM BLOOD Glucose-96 UreaN-24* Creat-0.9 Na-143
K-5.0 Cl-107 HCO3-24 AnGap-12
___ 06:00AM BLOOD K-5.0
___ 06:30AM BLOOD ALT-62* AST-70* AlkPhos-1619*
TotBili-1.8*
___ 06:30AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
___ 06:30AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
___ 04:49AM BLOOD Digoxin-0.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
2. Digoxin 0.125 mg PO DAILY
3. Linezolid ___ mg PO Q12H
4. Mycophenolate Sodium ___ 720 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Sodium Polystyrene Sulfonate 15 gm PO ASDIR Hyperkalemia
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. ValGANCIclovir 900 mg PO Q24H
9. Warfarin 5 mg PO DAILY
10. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Mirtazapine 7.5 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. Senna 8.6 mg PO BID
7. CycloSPORINE (Neoral) MODIFIED 175 mg PO Q12H
8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Maximum 6 of the 325 mg tablets daily
9. Sodium Polystyrene Sulfonate 15 gm PO ASDIR Hyperkalemia
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. HELD- Mycophenolate Sodium ___ 720 mg PO BID This medication
was held. Do not restart Mycophenolate Sodium ___ ___ discussed
with transplant MD.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
h/o liver transplant complicated by late Hepatic Artery
thrombosis
h/o bilioma with Enterococcus facium and Stenotrophomonas
maltophilia
Bile leak
Neutropenia
Depression
Malnutrition
Digoxin toxiciy/first degree av block
Afib
Klebsiella bacteremia ___
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// r/o infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size remains mildly enlarged, unchanged. Mediastinal and hilar contours
are similar. The pulmonary vasculature is not engorged. No focal
consolidation, pleural effusion, or pneumothorax is seen. Elevation of the
right hemidiaphragm is similar to the prior exam with minimal right basilar
atelectasis. No acute osseous abnormalities are demonstrated. Percutaneous
pigtail catheter projects over the epigastric region. Two additional PTBD
catheters are seen overlying the right upper quadrant. Right upper quadrant
vascular stent is also re-demonstrated.
IMPRESSION:
Mild right basilar atelectasis. Otherwise, no acute cardiopulmonary
abnormality.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: History: ___ with s/p liver transplant with jaund___, ___ loss
of low grade fevers X 1 week. has, multiple abdominal drains in place.// eval
for bilomas or biliairy stricture
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: ___ CT abdomen and pelvis with IV contrast, ___ liver gallbladder ultrasound
FINDINGS:
2 right-sided percutaneous intrahepatic biliary drainage catheters and a
pigtail drainage catheter within the left lobe of the liver are partially
visualized due to poor acoustic windows, and better assessed on the prior CT
abdomen and pelvis.
Visualization of the liver parenchyma is limited by overlying bandages. Liver
echotexture is heterogeneous and demonstrates scattered areas of ill-defined
hypoechogenicity and intraparenchymal gas particularly within the left hepatic
lobe, which correlate with prior areas of parenchymal fluid collections,
better assessed on the ___ CT abdomen and pelvis. There is no
intrahepatic biliary dilatation with pneumobilia noted. The common hepatic
duct measures 5 mm. There is no ascites or right pleural effusion.
The spleen is enlarged measuring 17.9 cm, without focal lesions.
DOPPLER: The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Resistive
index within the main hepatic artery is 0.55. peak systolic velocity in the
main hepatic artery is 51.6 centimeters/seconds, previously 89.5
centimeters/second. Appropriate arterial waveforms are seen in the right
hepatic artery and the left hepatic artery with resistive indices of 0.42, and
0.42, respectively, previously 0.43. The main portal vein and the right and
left portal veins are patent with hepatopetal flow and normal waveform.
Appropriate flow is seen in the hepatic veins and the IVC.
IMPRESSION:
1. Evaluation of the liver is somewhat limited due to overlying bandages.
2. Heterogeneous liver parenchyma with areas of intraparenchymal gas, most
notable in the left lobe which correlate with prior fluid collections which
were better seen in the ___ CT abdomen and pelvis.
3. Partially visualized drainage catheters as described above.
4. 17.9 cm splenomegaly.
5. Persistent low right and left hepatic artery resistive indices measuring
0.42, which may reflect upstream stenosis related to hepatic artery
thrombosis.
6. Remainder of the hepatic vasculature appears patent with appropriate
waveforms.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with fevers, jaundice and anemia
NO_PO contrast// eval for RP bleed, abscess in abdomen
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 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 22.5 mGy (Body) DLP =
1,172.5 mGy-cm.
Total DLP (Body) = 1,186 mGy-cm.
COMPARISON: CT abdomen and pelvis with contrast from ___
Duplex Doppler ultrasound from ___
FINDINGS:
LOWER CHEST: There has been been near complete interval resolution of
previously seen bilateral pleural effusions from ___. Minimal
bibasilar atelectasis present. No new focal consolidation is identified. The
cardiac size is not enlarged. Coronary artery calcifications are again seen.
Trivial pericardial effusion is minimally decreased from prior.
ABDOMEN:
HEPATOBILIARY: Patient is status post liver transplant. There is slight
interval improvement of the large fluid collection containing gas encompassing
the left hepatic lobe, measuring approximately 8.9 x 4.8 x 4.2 cm, previously
8.8 x 5.3 x 5.5 cm in ___. Left anterior percutaneous catheter
remains in unchanged position within the dominant collection. Left internal
biliary stent catheter within the larger collection courses through the left
hepatic duct and into the common bile duct to terminate within the duodenum,
unchanged in position.
There has been removal of a right lateral approach peripherally located
percutaneous pigtail catheter with overall stable appearance of the segment 6
peripheral ill-defined hypodense area measuring up to 10 mm. 2 right lateral
approach PTBD catheter are in unchanged position and course through the common
hepatic duct and terminate within the duodenum. Moderate intrahepatic
biliary dilatation persists which particularly involves the right anterior
superior ducts, unchanged. The gallbladder has been resected.
The main portal vein stent appears patent. Right posterior portal vein is
widely patent. The right anterior portal vein remains diminutive but patent.
The left portal vein is not visualized. There is also mild interval
improvement in the known portal venous confluence thrombus which extends into
the SMV (02:30), as compared to the prior study in ___.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is persistently enlarged, measuring 15.6 cm.
ADRENALS: The left adrenal gland is normal in size and shape. There is
unchanged 1.6 cm right adrenal hypodense lesion, previously described as
hematoma.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Note is again made of a small fat containing right lateral
ventral hernia (02:48).
IMPRESSION:
1. Mild interval decrease in the size of the dominant left hepatic lobe air
and fluid collection as compared to the prior study in ___.
2. Moderate intrahepatic biliary dilatation which in particular involves the
right superior hepatic ducts appears similar. Similar positioning of
right-sided PTBD catheters and left hepatic internal biliary stent.
3. Minimal interval improvement in known portal venous confluence thrombus as
compared to ___. Main portal vein stent appears patent.
4. Interval removal of a right lateral percutaneous approach drainage catheter
with no change in appearance of approximately 10 mm segment 6 ill-defined
hypodense collection.
5. Unchanged right adrenal hematoma.
6. Near complete resolution of previously seen bilateral pleural effusions.
7. No retroperitoneal hematoma or new abscess in the abdomen as clinically
questioned.
Radiology Report
INDICATION: ___ year old man with DDLT ___, now wth pancytopenia,
neutropenia, new fever// Please eval for infectious process
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiac silhouette is within normal limits.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: The abdomen and pelvis with contrast.
INDICATION: ___ s/p DDLT ___ complicated hepatic artery thrombosis,
left liver lobe infarct, bilateral biloma, R biliary dilatation/stricture, s/p
R PTBD and/post system, presents with anemia, neutropenic with new fever.
Evaluate for ductal dilation, PTBD position, evidence of new 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 4.5 s, 59.1 cm; CTDIvol = 16.9 mGy (Body) DLP = 998.3
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP =
21.8 mGy-cm.
Total DLP (Body) = 1,022 mGy-cm.
COMPARISON: CT studies of the abdomen and pelvis from ___ and ___.
FINDINGS:
LOWER CHEST: Bilateral dependent atelectasis. There has been a slight
interval increase in the bilateral pleural effusions, greater on the right
than on the left. Pericardial effusion is similar to the prior exam.
Coronary artery calcifications are again noted.
ABDOMEN:
HEPATOBILIARY: The patient is status post liver transplant. The liver
parenchyma appears heterogeneous and nodular. There is a pigtail catheter
terminating within the complex air and fluid collection in the left hepatic
lobe. This collection appears slightly smaller, now measuring up to 7.8 cm,
previously 8.9 cm (series 2, image 21). No new fluid collections are noted.
There is redemonstration of an internal biliary stent catheter with its
proximal tip within this collection, the catheter courses through the biliary
stent and terminates within the duodenum. 2 external biliary drains are
unchanged in position, also terminating within the duodenum. There is
persistent moderate intrahepatic biliary dilatation. The main portal vein
stent appears patent and there is an unchanged nonocclusive thrombus at the
portal confluence. There is also a small nonocclusive thrombus noted within
the SMV (series 2, image 41). The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is enlarged measuring up to 15.5 cm. The spleen shows
normal attenuation throughout, without evidence of focal lesions.
ADRENALS: Unchanged 1.8 cm right adrenal hypodense lesion, previously
characterized as hematoma. The left adrenal glands is normal in size and
shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is a short
approximately 7 cm segment involving the ascending colon which demonstrates
decreased wall enhancement, wall thickening, and adjacent fat stranding
(series 2, image 49). The CT findings are compatible with colitis. There is
a is small foci of air within the SMV as noted above (series 2, image 41),
which raises suspicion for ischemic colitis. The rectum is unremarkable. The
appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a very small fat containing umbilical hernia. 2 small
air foci in the low anterior abdominal wall are likely iatrogenic, sequela of
injections.
IMPRESSION:
1. Approximately 7 cm ascending colon segment with CT features consistent with
colitis, air focus within the SMV raises concern for ischemic colitis.
2. Small nonocclusive thrombus in the SMV. Unchanged nonocclusive thrombus at
the portal confluence.
3. Interval decrease in the size of the left hepatic lobe collection.
4. Moderate intrahepatic biliary dilatation, largely unchanged. Similar
position of biliary catheters and portal vein stent.
5. Small bilateral pleural effusions, right greater than left.
6. Unchanged right adrenal hematoma.
Radiology Report
INDICATION: ___ year old man with typhlitis and new onset abd pain// Please
eval for acute pathology including free subdiaphragmatic air*Patient cannot
leave floor, but please perform UPRIGHT KUB**
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
There is a nonspecific bowel gas pattern. No dilated loops of bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Two biliary drains project over the right upper quadrant. A pigtail drain
projects over the epigastrium, presumably within a fluid collection as on
prior CT.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No intraperitoneal free air. No bowel obstruction.
Radiology Report
EXAMINATION: MRCP
INDICATION: Please include down through area of colitis (at least to level of
umbilicus) ___ s/p DDLT ___ c/b HA thrombosis, left liver lobe infract,
b/l biloma, R biliary dilatation/stricture s/p R PTBD and/post system, p/w
anemia, neutropenic// Please include down through area of colitis (at least to
level of umbilicus) Evaluate biliary tree, in particular for obstruction in
setting of rising bilirubin.Evaluate for interval progression of right sided
colitis in setting of worsening abdominal pain.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT abdomen and pelvis ___, MRCP ___.
FINDINGS:
Lower Thorax: There is a trace left and small right pleural effusion.
Hepatobiliary: There is unchanged morphology of the transplant liver. The
gallbladder is surgically absent. Two PTBD stents are in place within the
anterior and posterior right intrahepatic bile ducts. Previously seen
segmental biliary duct dilation on prior MRCP has improved, with minimal focal
areas of dilation of peripheral biliary radicles most pronounced at the
hepatic dome. There remains hyperenhancement of the intrahepatic ducts
containing the PTBD as well as the common bile duct. The bile ducts otherwise
are not hyperenhancing.
Intrahepatic abscess continues to mildly decreased in size compared to the
prior MRCP, now measuring 8.3 x 4.0 cm, previously 10.0 x 5.1 cm on axial
images. A pigtail drainage catheter remains well-positioned within this
collection.
As seen previously, there is marked patchy geographic hepatic parenchymal
hyperenhancement which persists on more delayed phase imaging.
There is no ascites.
Pancreas: The pancreas is normal in morphology and signal intensity. There is
no pancreatic duct dilation.
Spleen: The spleen measures 15.4 cm.
Adrenal Glands: Again seen, is an intrinsically T1 hyperintense nodule in the
right adrenal gland measuring 1.7 x 1.8 cm with rim enhancement, likely a
adrenal hematoma. There is mild thickening of the left adrenal gland without
discrete nodularity.
Kidneys: The kidneys are symmetric in size. No focal renal lesions are seen.
There is no hydronephrosis.
Gastrointestinal Tract: There is no hiatal hernia. Large bowel loops at the
hepatic flexure are primarily decompressed and there is no significant
adjacent fat stranding. There is normal enhancement associated with this
bowel loop.
Lymph Nodes: There are no enlarged mesenteric or retroperitoneal lymph nodes.
Vasculature: There is no abdominal aortic aneurysm. Celiac axis and SMA as
well as the bilateral renal arteries are patent. Hepatic arteries are not
visualized. Again seen, is partially occlusive thrombus at the portal/SMV
confluence with partially occlusive thrombus extending into the SMV. The SMV
appears slightly more diminutive than on recent CT scan, question mild
progression of thrombus versus technical factors.
The main portal vein is not visualized secondary to stent, although vessel was
seen to be patent on CT scan from ___.
Portal vein supplying the lateral segment of the left lobe of the liver is
not visualized. Portal vein branch supplying the medial left lobe of the
liver is severely attenuated. The right anterior portal vein branch is
severely attenuated. The right posterior portal branch is patent.
The middle hepatic vein is patent. Neither the left or the right hepatic
veins are visualized.
Osseous and Soft Tissue Structures: There are no suspicious bony lesions.
There is no superficial soft tissue abnormality.
IMPRESSION:
1. Right anterior and posterior PTBDs in place with improved dilation of
segmental bile ducts compared to prior MRCP and similar in appearance to
recent CT. Persistent hyperenhancement surrounding the bile ducts containing
the drains is an expected finding.
2. Continued interval decrease of the still large left intrahepatic abscess
compared to prior MRCP, now measuring 8.3 x 4.0 cm on axial images.
3. Colon at the hepatic flexure is decompressed without wall thickening or
associated fat stranding, indicating improvement/resolution of suspected
colitis.
4. Partially occlusive thrombus in the portal vein and SMV. SMV thrombus may
be slightly increased compared to prior CT although this may be from technique
differences.
5. Stable thrombosis of the left and right hepatic veins. Similar appearance
of the intrahepatic portal veins with severe attenuation of the right anterior
and left medial portal veins. The left lateral portal vein is chronically
thrombosed.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// new R PICC 44cm, Contact
name: ___: ___
IMPRESSION:
In comparison with study of ___, there has been placement of a right
subclavian PICC line that extends to about the level of the cavoatrial
junction. Cardiac silhouette remains at the upper limits of normal in size
and there is no vascular congestion, pleural effusion, or acute focal
pneumonia.
Radiology Report
INDICATION: ___ year old man with a history of ETOH cirrhosis/___ s/p DDLT
___ with course complicated by re-operation POD 1 for plication of
diaphragm, bile leak requiring ercp/stent placement and ___ drainage, HAT
(remains occluded) with resultant left lobe necrosis, portal vein thrombosis
s/p lysis and stenting, bile duct stricture s/p right sided PTBD and large
left lobe liver abscess s/p drainage// PTBD check/reposition/exchange
COMPARISON: Prior PTBD placement from ___
TECHNIQUE: OPERATORS: Dr. ___, ___ attending, performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
1 mg of midazolam throughout the total intra-service time of 23 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: 1% lidocaine
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.5 min, 123 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing right anterior percutaneous
transhepatic biliary drainage access.
2. Over-the-wire cholangiogram through existing right posterior percutaneous
transhepatic biliary drainage access.
3. Exchange of both existing percutaneous trans-hepatic biliary drainage
catheters with a new ___ PTBD catheters.
4. Sinogram of left hepatic abscess catheter.
5. Exchange of existing left hepatic abscess catheter with new ___ catheter.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right/mid abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
right tubes were injected with dilute contrast. The images were stored on
PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right anterior catheter was cut and a
___ wire was advanced through the catheter into the duodenum. The
catheter was removed over the wire and a ___ sheath was placed over the wire
and a pull-back cholangiogram was performed. Next, the right posterior
catheter was cut and ___ wire was advanced through the catheter into the
duodenum. The catheter was removed over the wire and a ___ sheath was placed
over the wire and a pull-back cholangiogram was performed. No biliary leak was
demonstrated. Next, sequentially, ___ biliary drainage catheters were then
placed over each wire, and advanced into the duodenum. The wires and inner
stiffeners were removed, the catheters were flushed, the loops were formed,
and contrast confirmed good location and antegrade drainage. Given the
absence of a leak and good antegrade flow, the catheters were capped for
internal drainage and sterile dressings were applied.
On the left, a sinogram was performed through the existing tube demonstrating
a cavity around the pigtail catheter. Thick debris was aspirated from the
catheter. Next, similarly, the pigtail catheter was cut and ___ wire
was advanced through the catheter into cavity. The catheter was removed over
the wire and a 12 ___ pigtail catheter was advanced into the cavity. The
wire and inner stiffener were removed, the catheter was flushed, the loop was
formed, the catheter was attached to a bulb suction and sterile dressings were
applied. The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Two existing right ___ percutaneous transhepatic biliary drainage
catheters were in good position and patent.
2. Cholangiogram of the right anterior duct system demonstrated no discrete
biliary leak and good antegrade drainage.
3. Cholangiogram of the right posterior duct system demonstrated no discrete
biliary leak and good antegrade drainage.
4. Both catheters were replaced with ___ biliary catheters, and capped for
internal drainage.
5. Sinogram of the left demonstrated a persistent cavity around the catheter,
with debris aspirated. No definite connection of contrast to the hepatic duct
confluence or right indwelling biliary drains. Given the size of the residual
cavity, the abscess drain was replaced with another ___ drain.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new ___ catheters and replacement of left abscess cavity
catheter.
Radiology Report
INDICATION: ___ year old man with PTBDs that are capped with drainage around
the PTBD// Please perform cholangiogram
COMPARISON: Previous PTBDs
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 12 mins 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: As above
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.4 min, 15 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing right percutaneous
transhepatic biliary drainage access x 2
2. Exchange of the existing percutaneous trans-hepatic biliary drainage
catheter with a new ___ PTBD catheter.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right/mid abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
right tubes were injected with dilute contrast. The images were stored on
PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right anterior catheter was cut and a
___ wire was advanced through the catheter into the duodenum. A pull back
cholangiogram was then performed with findings as outlined below. The
catheter was removed over the wire and a 10 ___ percutaneous trans hepatic
biliary drainage catheter was advanced into the duodenum. Side holes were
positioned above and below the level of obstruction to facilitate internal
drainage. The wire and inner stiffener were removed, the catheter was flushed,
the loop was formed, the catheter was attached to a bag and sterile dressings
were applied.
On the right posterior, similarly the catheter was cut and ___ wire was
advanced through the catheter into the duodenum. A pull back cholangiogram was
then performed with findings as outlined below. The catheter was removed over
the wire and a 10 ___ percutaneous transhepatic biliary drainage catheter
was advanced into the duodenum. Side holes were positioned above and below the
level of obstruction to facilitate internal drainage. The wire and inner
stiffener were removed, the catheter was flushed, the loop was formed, the
catheter was attached to a bag and sterile dressings were applied.
The left abscess drain was injected with contrast.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right anterior and posterior percutaneous transhepatic biliary drainage
catheters.
2. Cholangiogram showing initial right posterior tube was clogged.
3. Successful exchange of both right percutaneous transhepatic biliary
drainage catheters with new 10 ___ catheters.
4. Injection of left hepatic abscess drain; injection shows opacification of
right biliary tree. Continued small cavity and debris in the left hepatic
lobe.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new ___ catheters.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p DDLT ___ c/b HAT w L lobe necrosis abscess s/p ___
drain, PVT s/p lysis/stent, bile leak stricture s/p R PTBD x2, p/w
neutropenia ___ medication) and colitis (now resolved) now with fevers//
?infection
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest radiographs dated ___
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates an unchanged
cardiomediastinal silhouette and pulmonary vasculature. A right-sided PICC
line is in unchanged position. New since the prior examination is left
basilar opacity, which may represent pneumonia in the appropriate clinical
context. There is no sizable pleural effusion or pneumothorax.
IMPRESSION:
Left basilar opacity may represent pneumonia in the appropriate clinical
context.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS
INDICATION: ___ s/p DDLT ___ c/b HAT w L lobe necrosis abscess s/p ___
drain, PVT s/p lysis/stent, bile leak stricture s/p R PTBD x2, p/w
neutropenia ___ medication) and colitis (now resolved). Now neutropenic,
bacteremic, recent fevers. Please use PO IV contrast.Thank you.// please
evaluate for collection/abscesses/infection. please use po iv contrast
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 57.2 cm; CTDIvol = 17.3 mGy (Body) DLP = 986.6
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP =
21.8 mGy-cm.
Total DLP (Body) = 1,010 mGy-cm.
COMPARISON: MRI dated ___
FINDINGS:
LOWER CHEST: There is minimal subsegmental atelectasis at the lung bases.
Trace right pleural effusion noted.
ABDOMEN:
HEPATOBILIARY:
Patient is status post liver transplant. There has been interval decrease in
size of the left lobe abscess now measuring 3 x 6 cm, previously 4 x 8 cm.
Percutaneous pigtail drainage catheter remains in situ. There is no evidence
of a new collection in the liver. No suspicious focal liver lesion
identified. The PTBD catheters within the anterior and posterior right
intrahepatic ducts are again noted and remain unchanged in position. Minimal
intrahepatic biliary duct dilatation is unchanged.
PANCREAS: The pancreas is slightly atrophic but demonstrates a normal
attenuation. There is no focal pancreatic lesion or duct dilatation. There
is no peripancreatic stranding.
SPLEEN: Spleen is enlarged measuring 15 cm in craniocaudal length. There is
no focal splenic lesion.
ADRENALS: 15 mm right adrenal nodule is stable. Left adrenal gland is
unremarkable.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR:
There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted.
Not again made a portal vein stent which appears patent. Partially occlusive
thrombus in the SMV appears to have slightly decreased in size. There is
chronic occlusion of the lateral branch of the left portal vein. Left medial
branch and anterior branch of the right portal vein are attenuated similar to
the prior study. Posterior branch of the right portal vein is patent.
Note is again made of chronic occlusion of the left hepatic vein and
attenuation of the right hepatic vein. Middle hepatic vein is patent.
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 new source of infection in the abdomen and pelvis. In particular, no
evidence of an abscess or organized collection.
2. Interval decrease in size of the left hepatic abscess.
3. Stable splenomegaly
4. Partially occlusive thrombus in the ___ appears to have slightly decreased
in size. Chronic left lateral portal vein branch thrombosis stable attenuation
of the right anterior and left medial portal veins.
Radiology Report
INDICATION: ___ year old man with mild leakage around lateral PTBD and minimal
output of medial PTBD.// please perform cholangiogram.
COMPARISON: CT abdomen pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ Radiologist and Dr.
___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 51 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: See medications above
CONTRAST: 60 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 13.3 minutes, 70 mGy
PROCEDURE:
1. Antegrade cholangiogram through existing right anterior and right posterior
percutaneous transhepatic biliary drains.
2. Pull-back cholangiogram through existing right anterior and right posterior
percutaneous transhepatic biliary tracts.
3. Placement of a new 10 ___ right anterior biliary drainage catheter.
4. Placement of a new 10 ___ right posterior biliary drainage catheter.
5. Left hepatic abscessogram and cone beam CT.
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 upper abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
right tubes were injected with dilute contrast. The images were stored on
PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right posterior catheter was cut and a
___ wire was advanced through the catheter into the duodenum. The
catheter was removed over the wire and exchanged for a 7 ___ x 25 cm
sheath. The right anterior catheter was cut and ___ wire was advanced
through the catheter into the duodenum. The catheter was removed over the
wire and exchanged for a 7 ___ x 25 cm sheath.
A right posterior pull back cholangiogram was then performed with findings as
outlined below. A right anterior pull-back cholangiogram was then performed
with findings as outlined below. A new right posterior 10 ___ percutaneous
trans hepatic biliary drainage catheter was advanced into the duodenum. Side
holes were positioned above and below the level of obstruction to facilitate
internal drainage. The wire and inner stiffener were removed, the catheter was
flushed, the loop was formed, the catheter was attached to a bag. A new right
anterior 10 ___ percutaneous transhepatic biliary drainage catheter was
advanced into the duodenum. Side holes were positioned above and below the
level of obstruction to facilitate internal drainage. The wire and inner
stiffener were removed, the catheter was flushed, the loop was formed, the
catheter was attached to a bag.
Next, contrast was injected into the existing left 8 ___ abscess drain.
Rotational cone-beam CT angiography was performed to help delineate the
anatomy and to evaluate abscess-biliary communication. Multiplanar CT images
were reconstructed and 3D volume-rendered images of the biliary anatomy
required post-processing on an independent workstation under direct physician
___. These images were used in the interpretation, decision making
for intervention and reporting of this procedure.
Sterile dressings were then applied. The patient tolerated the procedure
well.
FINDINGS:
1. Initial imaging demonstrated the right posterior percutaneous transhepatic
biliary drainage catheter was partially pulled back with tip remaining just
within the duodenum. The right anterior percutaneous transhepatic biliary
drainage catheter and abscess drain was in good position.
2. Right posterior and right anterior antegrade and pull-back cholangiograms
demonstrate good passage of contrast into the small bowel, no detectable bile
leak and no significant intrahepatic biliary duct dilatation.
3. Successful exchange of 10 ___ percutaneous transhepatic biliary drainage
catheters with new 10 ___ catheters in good position.
4. Abscessogram demonstrating the 8 ___ catheter in good position within
the abscess cavity and communication of the abscess with the biliary tree.
Subsequent cone beam CT with contrast injection through the abscess drain
demonstrated communication of the abscess with the left biliary tree.
IMPRESSION:
Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new 10 ___ catheters.
Abscessogram and cone beam CT demonstrating communication of the abscess
cavity with the left biliary tree. No communication with the right biliary
tree was identified.
RECOMMENDATION(S): Will discuss plans with the primary team regarding
possible placement of a new left-sided PTBD to divert passage of bile from the
abscess cavity allowing for resolution.
Radiology Report
INDICATION: ___ year old man with left hepatic abscess which communicates with
the left biliary tree. Plan to place new left sided PTBD to decompress the
left biliary system to allow the abscess cavity to collapse and heal.// Please
place new left PTBD.
COMPARISON: Numerous prior interventions including from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: As per anesthesia team
CONTRAST: 95 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.1 min, 60 mGy
PROCEDURE:
1. Transabdominal ultrasound.
2. Left abscess drain fistulagram
3. Fluoroscopic guided segment 4 percutaneous transhepatic bile duct access.
4. Segment 4 cholangiogram as well as pull-back cholangiogram to evaluate for
pleural transgression
5. ___ segment 4 biliary drain.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right and mid
abdomen was prepped and draped in the usual sterile fashion.
Initially, the left abscess drain was injected which was utilized to opacify
the segment 4 ducts. Then, under ultrasound and fluoroscopic guidance, a 21G
Cook needle was advanced into segment 4biliary system. Images of the access
were stored on PACS. Once return of bilious fluid was identified, a GT
Glidewire wire was advanced under fluoroscopic guidance into the common bile
duct. A skin ___ was made over the needle and the needle was removed over the
wire. Initially, the inner portion of the Accustick set was advanced into the
biliary tree. A hemostatic valve was placed and a pull-back cholangiogram
performed all the way to the needle entry site into the liver to evaluate for
pleural transgression. No transgression was seen therefore the Accustick was
re-assembled and the entire set placed. Then, the Glidewire was removed and a
___ was placed in the bowel. Then, over the ___ wire a 10 ___
internal external drain was placed.
The wire was removed. The pigtail was formed. Contrast injection confirmed
appropriate position. The catheter was flushed with saline, secured with stay
sutures to the skin and sterile dressings were applied. The catheter was
attached to a bag.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Left-sided abscess drained communicating with segment 4 ducts.
2. Fluoroscopic leak guided segment 4 PTBD placement.
3. Pull-back cholangiogram demonstrating no pleural transgression
IMPRESSION:
Successful placement of the 10 ___ internal external drain to segment 4
ducts which communicate with the left-sided abscess drain.
RECOMMENDATION(S): All 4 drains are currently to bag drainage. The 3 drains
entering the right side of the abdomen can be capped as long as the patient is
afebrile, and the drainages nonbloody. The central drain should remain to
bag.
Radiology Report
INDICATION: ___ year old man with s/p DDLT c/b multiple bilomas, s/p PTBD, now
leaking// PTBD check/change
COMPARISON: Biliary catheter change ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 17 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: None
CONTRAST: 50 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.6 min, 38 mGy
PROCEDURE:
1. Over-the-wire cholangiogram through existing right anterior, right
posterior, and left (segment IV) percutaneous transhepatic biliary drainage
access.
2. Exchange of the existing percutaneous trans-hepatic biliary drainage
catheters (right anterior, right posterior, and left (segment IV) for new 10
PTBD catheters.
3. Left intrahepatic abscess drainage check.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right and mid abdomen was prepped and draped in the usual
sterile fashion.
Initial scout images showed biliary drain in the appropriate position. The
right anterior, right posterior and left (segment IV) tubes were injected with
dilute contrast. The images were stored on PACS.
The left intrahepatic external drainage catheter ___ APDL) was injected with
contrast. No exchange was performed due to it's patency. The tube was
attached to gravity drainage.
Each biliary catheter sites were injected with subcutaneous injection of 1%
lidocaine and instillation of lidocaine jelly. Sequentially, the left
(segment IV), right anterior, and right posterior catheters were cut and a
___ wire was advanced through each catheters into the duodenum. The
catheters were sequentially removed over the wire and ___ percutaneous
transhepatic biliary drainage catheters were advanced into the duodenum. Side
holes were positioned above and below the level of obstruction to facilitate
internal drainage. The wire and inner stiffeners were removed, the catheters
were flushed, their loop was formed, the catheters were all capped.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Patent indwelling left (segment IV), right anterior, and right posterior
percutaneous transhepatic biliary drainage catheters.
2. Left intrahepatic external drainage catheter demonstrates a contracted
cavity, however, persistent communication to the bowel via the left biliary
radicals exists.
3. Successful exchange of left (segment IV), right anterior, and right
posterior percutaneous transhepatic biliary drainage catheters with new 10
___ catheters.
IMPRESSION:
1. Successful exchange of existing percutaneous transhepatic biliary drainage
catheters for new ___ catheters.
2. Left intrahepatic abscess catheter check.
RECOMMENDATION(S): 1. Right anterior, right posterior, and left (segment IV)
drains will be kept capped. LFTs and Tbili tomorrow.
2. Left intrahepatic abscess catheter will be attached to gravity bag.
Radiology Report
INDICATION: ___ s/p DDLT ___ c/b HAT w L lobe necrosis abscess s/p ___
drain, PVT s/p lysis/stent, bile leak stricture s/p R PTBD x2 and L PTBD x
1Patient on Apixiban, evaluate the left liver lobe for evidence of decrease in
abscess/fluid collection, assess for perihepatic fluid collection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 53.7 cm; CTDIvol = 17.3 mGy (Body) DLP = 929.8
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.8 s, 0.5 cm; CTDIvol = 43.6 mGy (Body) DLP =
21.8 mGy-cm.
Total DLP (Body) = 953 mGy-cm.
COMPARISON: Prior CT of the abdomen pelvis dated ___ and MRCP dated
___.
FINDINGS:
LOWER CHEST: A small nonhemorrhagic right pleural effusion is slightly
increased from the prior study. The lung bases are otherwise clear without
evidence of infection. A small pericardial effusion has also increased.
There is moderate coronary arterial calcification.
ABDOMEN:
HEPATOBILIARY: There is a left upper quadrant pigtail catheter located within
the periphery of a gas and fluid containing collection in the left hepatic
lobe, which measures up to 7.0 x 3.4 cm, not significantly changed from the
prior study at which time it measured 7.1 x 3.7 cm when measured in similar
planes (02:18). An adjacent hypodensity likely represents a loculation of the
same collection measures up to 2.0 x 1.9 cm, previously 2.0 x 1.9 cm.
Heterogeneity of the underlying parenchyma in segment III and IVB is stable
from the prior study. Patient has undergone placement of 2 right-sided PTBDs,
which appear well-positioned with stable mild intrahepatic biliary ductal
dilatation and minimal surrounding hypodensity. There has been interval
placement of an additional more superior right upper quadrant PTBD with
improvement of the previously seen biliary ductal dilatation. There is no
suspicious liver lesion. The IVC anastomosis related to prior liver
transplant is unchanged. A stent within the main portal vein is unchanged.
The right anterior and posterior portal veins appear patent. The left portal
vein is attenuated and difficult to visualize due to streak artifact from the
adjacent hardware, with the visualized portion appearing patent. A subtle
hypodensity in segment VII is unchanged, possibly retraction injury related to
surgery (02:15).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is moderate splenomegaly measuring up to 15.1 cm (601:32).
There is no focal lesion.
ADRENALS: The right adrenal gland is normal in size and shape. Ill-defined
central hypodensity within the right adrenal gland was previously
characterized as a likely adrenal hematoma on prior MRI of ___.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate multilevel degenerative changes are noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Unchanged size and configuration of the left hepatic lobe abscess.
2. Slight interval increase in small nonhemorrhagic left pleural effusion and
small pericardial effusion.
3. Interval placement of a right upper quadrant PTBD with improvement of the
previously seen biliary ductal dilatation.
4. Patent main portal vein stent and patent right portal veins. Visualized
portions of the left portal vein appear attenuated but patent.
Radiology Report
INDICATION: ___ year old man with three biliary drains- medial drain pulled
back 4-5 cm, for tube evaluation/ replacement// ___ year old man with three
biliary drains- medial drain pulled back 4-5 cm, for tube evaluation/
replacement
COMPARISON: Biliary catheter check ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
1 mcg of fentanyl and 50 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: None
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.6 min, 78 mGy
PROCEDURE:
1. Over-the-wire sinogram through existing ___ F left intrahepatic drain
2. Exchange of the existing percutaneous ___ F left intrahepatic drain over
wire for a new, ___ F APDL
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 mid abdomen was prepped and draped in the usual sterile fashion.
Initial scout images showed biliary drain in the appropriate position. The
left-most tube of concern was injected with dilute contrast. The images were
stored on PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the catheter was cut and a stiff Amplatz
wire was advanced into the collapsed left intrahepatic cavity. A new ___ F
APDL was exchanged over wire. Pigtail was formed and contrast was injected to
confirm adequate positioning. The wire and inner stiffener were removed, the
catheter was flushed, the loop was formed, the catheter was attached to a bag
and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Despite concern of malpositioned left-most intrahepatic biliary drain, the
position of the pigtail was unchanged in positioning when comparison prior
study. Injection of contrast through the indwelling tube demonstrated
persistent filling of the right posterior and left intrahepatic biliary tree
and duodenum, confirming complex communication of these entities. The
intrahepatic cavity remains collapsed around the pigtail.
2. Successful exchange of left intrahepatic drainage catheter for new ___ F
APDL. Contrast injection confirms appropriate final position.
IMPRESSION:
Successful over-the-wire exchange of existing left intrahepatic drainage
catheter for new ___ F APDL, in appropriate position.
RECOMMENDATION(S): Left intrahepatic drain attached to gravity bag.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, s/p Fall
Diagnosed with Anemia, unspecified, Fever, unspecified, Fall on same level, unspecified, initial encounter, Long term (current) use of anticoagulants
temperature: 98.6
heartrate: 90.0
resprate: 17.0
o2sat: 100.0
sbp: 119.0
dbp: 69.0
level of pain: 2
level of acuity: 2.0 | ___ y/o male with history of liver transplant ___ that was
complicated by late hepatic artery thrombosis, left liver lobe
necrosis & abscess s/p ___ drain, portal vein thrombosis s/p
lysis/stent, bile leak & stricture with Percutaneous
transhepatic drain placement. Infectious complications included
biloma with Enterococcus faecium and Stenotrophomonas
maltophilia on long term IV antibiotics Linezolid. He was
admitted with neutropenia and anemia with a hematocrit of 18%.
By HD 4 he was having febrile neutropenia and neutropenic
enterocolitis.
Five units of RBCs were given over first 3 days of hospital
course with appropriate hematocrit response. Hematocrit remained
about 26% on subsequent days.
.
On admission WBC was 1000, and decreased as low as 400 with an
ANC as low as 48. Linezolid was discontinued as this was the
most likely cause of neutropenia. IV Dapto and Ceftriaxone were
restarted. Infectious disease was following and recommended
antibiotic initial end date of ___. PTBD exchange was
delayed until neutropenia was resolved off Linezolid and
Filgrastim injections.
Mycophenolate was held the entire hospitalization. Cyclosporine
was continued as singe agent therapy. Immunknow was initially
very low at 84 then increase to the mid ___. CMV VL were
undetectable.
.
Afib which had been managed with Digoxin was mainly under
control but he was having asymptomatic bradycardia as well as a
supertherapeutic digoxin level. After consultation with
cardiology the digoxin was discontinued and low dose metoprolol
was started with good management of the AFib.
Heparin drip was used for anticoagulation around all procedures.
After drain exchanges and ERCP were done, warfarin was resumed
with goal 2.5-3.5 for the portal vein thrombus and also for the
AFib. Please note on CT there was notation of small nonocclusive
thrombus in the SMV and unchanged nonocclusive thrombus at the
portal confluence. Over hospital course, anticoagulation
management was changed to apixiban.
.
On HD 4, the patient spiked a fever to 102. CT was done showing
Approximately 7 cm ascending colon segment with CT features
consistent with colitis, air focus within the ___ raises concern
for ischemic colitis. Because of neutropenia, there was concern
for neutropenic enterocolitis. He was kept NPO with serial
abdominal exams. This ultimately resolved, he was allowed to
resume diet, and the WBC was back in the 5 range after multiple
doses of filgrastim and discontinuation of linezolid with bone
marrow recovery.
.
Once WBC had recovered to normal levels, the PTBDs were
exchanged and capped, and he also underwent ERCP where the
existing stent was removed, and not replaced.
.
Patient remained on a heparin drip while awaiting therapeutic
INR. He has receiving warfarin 5 mg daily that was later changed
to
.
On ___ he was febrile to 102.2. Blood cultures were sent that
showed BCx GNR. Ceftaz/flagyl were started and culture isolated
Klebsiella sensitive to ___. He was switched to Meropenem and
completed a ___ PICC line was placed for planned
long term IV antibiotics
WBC decreased to 1.0. Filgrastim was given. Bactrim was switched
to Atovaquone with improvement in WBC. Blood cultures remained
negative.
On ___, the PTBDs were exchanged with new 10 ___ catheters
for concern for obstruction given increased alk phos.
Abscessogram and cone beam CT demonstrated communication of the
abscess cavity with the left biliary tree and no communication
with the right biliary tree was identified. On ___, ___
performed a pull back cholangiogram demonstrating no pleural
transgression and placed a 10 ___ internal external drain to
segment 4 ducts which communicate with the left-sided abscess
drain. The right PTBDs were capped. However, he leaked around
the insertion site of the posterior right ptbd. The PTBDs were
uncapped and on ___, ___ exchanged the right posterior, right
anterior and left PTBD. These were successfully capped without
drainage or fever.
Alk phos increased to 1500s. JP output averaged 10cc/24 hours.
The JP was dislodged. CT of the abd was done to eval
demonstrating unchanged size and configuration of the left
hepatic lobe abscess. Slight interval increase in small
nonhemorrhagic left pleural effusion and small pericardial
effusion. There was improvement of the previously seen biliary
ductal dilatation. The main portal vein stent and right portal
veins were patent. Visualized portions of the left portal vein
appear attenuated but patent. ___ was able to exchange the pitail
drain to a ___ Fr. He tolerated this well with slight increase in
output to ___ of tan/cloudy drainage.
Given improvement in bilioma, ID recommended discontinuing
Daptomycin. This was done on ___. He remained afebrile and
felt well. He was cleared for home by ___ was
arranged to follow him for PTBD (3) and pigtail drain care. He
was discharged to home in stable condition. He was tolerating
regular food with nutritional supplements. Weight was 80.5kg on
discharge up from admission weight of 78kg.
Immunosuppression consisted of single drug cyclosporine. Most
recent doses and levels as follows.
___ CSA 175/175 (233)
___ CSA 175/175
___ CSA 175/175 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending: ___.
Major Surgical or Invasive Procedure:
___ guided tap of knee effusion
MRI of lumbar spine
attach
Pertinent Results:
ADMISSION LABS:
___ 09:55AM BLOOD WBC-7.0 RBC-2.64* Hgb-7.1* Hct-25.5*
MCV-97 MCH-26.9 MCHC-27.8* RDW-19.1* RDWSD-67.1* Plt ___
___ 09:55AM BLOOD Neuts-60.0 ___ Monos-12.6 Eos-3.6
Baso-0.7 Im ___ AbsNeut-4.18 AbsLymp-1.55 AbsMono-0.88*
AbsEos-0.25 AbsBaso-0.05
___ 12:32PM BLOOD ___ PTT-56.0* ___
___ 09:55AM BLOOD Glucose-61* UreaN-34* Creat-2.3*# Na-140
K-3.7 Cl-97 HCO3-32 AnGap-11
___ 09:55AM BLOOD ALT-23 AST-57* AlkPhos-180* TotBili-0.4
___ 09:55AM BLOOD cTropnT-0.08* proBNP-4427*
___ 04:15PM BLOOD cTropnT-0.07*
___ 09:55AM BLOOD Albumin-2.0* Calcium-8.7 Phos-3.9 Mg-2.0
Iron-34
___ 09:55AM BLOOD calTIBC-204* Ferritn-80 TRF-157*
___ 06:03AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:55AM BLOOD CRP-98.5*
___ 06:03AM BLOOD HCV Ab-NEG
___ 10:11AM BLOOD Lactate-1.9
URINE STUDIES:
___ 02:40PM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 02:40PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 02:40PM URINE RBC-24* WBC->182* Bacteri-MANY*
Yeast-FEW* Epi-1
___ 02:40PM URINE Hours-RANDOM Creat-88 Na-53
___ 02:40PM URINE Osmolal-468
___ 10:25AM STOOL CDIFPCR-POS* CDIFTOX-NEG
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC 1 MCG/ML test result performed by Etest.
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
Daptomycin MIC 2 MCG/ML test result performed by Etest.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
| ENTEROCOCCUS FAECALIS
| |
AMPICILLIN------------ =>32 R <=2 S
DAPTOMYCIN------------ S S
LINEZOLID------------- 2 S 2 S
PENICILLIN G---------- =>64 R 4 S
VANCOMYCIN------------ =>32 R =>32 R
===================================================
Foot Films (___) - IMPRESSION:
1. No acute fracture or dislocation.
2. Re-demonstration of a large soft tissue defect overlying the
left heel and
calcaneus. No new osseous erosion is identified.
CXR - IMPRESSION:
Mild pulmonary vascular congestion with a trace right pleural
effusion. No
focal consolidation.
CT A/P - IMPRESSION:
1. Cirrhotic liver. No splenomegaly. Small volume ascites.
2. Pancolonic diverticulosis without evidence of acute
diverticulitis.
3. Small right pleural effusion with adjacent compressive
atelectasis.
RLE U/S - IMPRESSION:
1. No evidence of deep venous thrombosis in the visualized right
lower
extremity veins.
2. Nonvisualization of the right peroneal veins.
3. Small ___ cyst is demonstrated in the right medial
popliteal fossa.
TTE - IMPRESSION: Severe biventricular systolic function. Trace
AR. Mild to moderate MR. ___ TR. ___ pulmonary HTN.
There are no obvious vegetations on the MV, TV, or AV. There is
a lead seen in the RA/RV which appears thickened but without
obvious vegetation. If there is clinical suspicion for IE, a TEE
is a better study to look for IE.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CefTRIAXone 1 gm IV Q24H
3. Salonpas (methyl salicylate-menthol) ___ % topical DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Rosuvastatin Calcium 20 mg PO QPM
8. Acetaminophen 1000 mg PO Q8H
9. Gabapentin 400 mg PO QHS
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Senna 8.6 mg PO BID
13. TraZODone 25 mg PO QHS:PRN insomnia
14. BuPROPion XL (Once Daily) 150 mg PO DAILY
15. DULoxetine ___ 40 mg PO DAILY
16. Furosemide 20 mg PO DAILY
17. ProMod Protein (protein supplement) 30 ml oral BID
18. Ascorbic Acid ___ mg PO BID
19. Levothyroxine Sodium 175 mcg PO DAILY
20. MetFORMIN (Glucophage) 500 mg PO BID
21. ___ 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
22. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO BID
End date: ___. ___ 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 1000 mg PO Q8H
4. Ascorbic Acid ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. BuPROPion XL (Once Daily) 150 mg PO DAILY
7. DULoxetine ___ 40 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Gabapentin 400 mg PO QHS
10. Levothyroxine Sodium 175 mcg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
16. Polyethylene Glycol 17 g PO DAILY
17. ProMod Protein (protein supplement) 30 ml oral BID
18. Rosuvastatin Calcium 20 mg PO QPM
19. Salonpas (methyl salicylate-menthol) ___ % topical DAILY
20. Senna 8.6 mg PO BID
21. TraZODone 25 mg PO QHS:PRN insomnia
22. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Enterococcal UTI and Bacteremia
___
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with hypoxia, osteo// CXR: ?pna, L foot: ?osteo
TECHNIQUE: AP and lateral views of the chest provided.
COMPARISON: Multiple prior chest radiographs dating back to ___, most recently ___.
FINDINGS:
A left pectoral AICD is in unchanged position. A right upper extremity PICC
line tip projects over the proximal right atrium, as before. A right IJ
central venous catheter has been removed.
Lung volumes are slightly decreased bilaterally. Perihilar opacities
bilaterally may represent bronchovascular crowding and/or mild pulmonary
vascular congestion. There is no focal consolidation. There may be a trace
right pleural effusion. There is no pneumothorax. The cardiomediastinal
silhouette is stable.
IMPRESSION:
Mild pulmonary vascular congestion with a trace right pleural effusion. No
focal consolidation.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with hypoxia, osteo// CXR: ?pna, L foot: ?osteo
TECHNIQUE: AP, oblique and lateral views of the left foot were obtained.
COMPARISON: Left foot radiographs dated ___, ___ and
___.
FINDINGS:
Re-demonstrated are postsurgical changes in the left heel and calcaneus.
Re-demonstrated is a large skin defect along the heel. There is no evidence
of new osseous erosion. Soft tissue swelling is again noted along the plantar
aspect of the foot.
There is no acute fracture or dislocation. Arthropathic changes in the
hindfoot, midfoot and forefoot are again noted. There is unchanged periosteal
reaction surrounding the second through fourth metatarsals. Surgical clips
again project over ___ fat pad.
IMPRESSION:
1. No acute fracture or dislocation.
2. Re-demonstration of a large soft tissue defect overlying the left heel and
calcaneus. No new osseous erosion is identified.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with abd pain, distension, diarrhea,
recent abx useNO_PO contrast// Collitis, obstruction
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,472.0 mGy-cm.
Total DLP (Body) = 1,472 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: There is a small, simple appearing right pleural effusion with
adjacent compressive atelectasis. There is no left pleural effusion. There
is also subsegmental atelectasis in the left lower lobe. There is no evidence
of pericardial effusion. The distal end of a pacemaker lead terminates in the
left ventricle. The tip of a PICC is also seen at the cavoatrial junction.
ABDOMEN:
HEPATOBILIARY: The liver is shrunken and nodular compatible with cirrhosis.
There is a small amount of perihepatic ascites. Absence of intravenous
contrast and streak artifact from the patient's arms limits assessment for
focal lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is surgically absent.
PANCREAS: There is moderate diffuse atrophy of the pancreas. Subcentimeter
hypodensities throughout the pancreas seen on prior contrast enhanced CTs of
the abdomen are not well assessed on the current examination. There is no
main ductal dilatation. Stranding about the pancreatic head and duodenum is
likely a component of overall diffuse mesenteric edema.
SPLEEN: The spleen is normal in size, measuring 10.1 cm in craniocaudal
dimension.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops are
normal in caliber. There is extensive pancolonic diverticulosis, without
focal wall thickening or pericolonic fat stranding. The appendix is not
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace free fluid in pelvis.
REPRODUCTIVE ORGANS: There is a small fibroid in the anterior uterine fundus.
No adnexal abnormalities are identified.
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.
There is severe osteoarthritis of both hips.
SOFT TISSUES: There is mild diffuse anasarca. Soft tissue nodules in the
anterior abdominal wall subcutaneous tissues may be related to prior
injections.
IMPRESSION:
1. Cirrhotic liver. No splenomegaly. Small volume ascites.
2. Pancolonic diverticulosis without evidence of acute diverticulitis.
3. Small right pleural effusion with adjacent compressive atelectasis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with hx DVT, now with RLE edema/pain// pls eval
for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial. However the right peroneal veins are
not demonstrated. There is extensive soft tissue edema involving the calf.
There is normal respiratory variation in the common femoral veins bilaterally.
There is a small anechoic collection in the right medial popliteal fossa
distance with a (___) cyst which measures 3.3 x 0.8 x 2.2 cm.
IMPRESSION:
1. No evidence of deep venous thrombosis in the visualized right lower
extremity veins.
2. Nonvisualization of the right peroneal veins.
3. Small ___ cyst is demonstrated in the right medial popliteal fossa.
Radiology Report
EXAMINATION: Right hip radiographs, two views, and pelvis radiograph, single
AP view.
INDICATION: Left hip pain. Bacteremia.
COMPARISON: Prior study from ___.
FINDINGS:
Right hip joint space appears mildly narrowed. The left appears preserved in
width. However, on each side, as before, there are large marginal
osteophytes. Degenerative changes are substantial but not well characterized
along lower lumbar facets. Sacroiliac degenerative changes are mild. Pubic
symphysis is mildly narrowed. There is no evidence of fracture, dislocation
or lysis. No definite change.
IMPRESSION:
No evidence of acute pathology.
Please note that right hip radiographs were acquired, not left-sided
radiographs. Study does include a full radiograph of the pelvis, however. If
dedicated left hip radiographs are needed clinically, then the patient could
return to the department to obtain these.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) RIGHT
INDICATION: ___ year old woman with R knee effusion concerning for septic
joint. has known RA// look for bony changes associated with septic knee
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of right knee
COMPARISON: Radiographs dated ___
IMPRESSION:
Only minimally decreased joint spaces along the medial and lateral
compartments. Irregularity of the medial femoral condyle articular surface,
unchanged from prior. Tricompartmental osteophytosis. Severe degenerative
changes of the patellofemoral compartment. No large joint effusion. Pre and
infrapatellar subcutaneous soft tissue edema. No acute fractures. Patellar
enthesopathy. Additional osseous irregularity of the tibial spines and
femoral intercondylar notch.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman with right knee effusion concerning for septic
joint. Rheum unable to aspirate// evaluate for right knee effusion
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right knee.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right knee. At the popliteal fossa there is a ___ cyst that measures
approximately 3.0 x 0.8 cm. Trace effusion is seen along the medial
compartment. A small effusion underlies the quadriceps tendon. A small joint
effusion is at the lateral aspect of the knee which extends superiorly.
IMPRESSION:
1. Targeted ultrasound of the right knee demonstrates small effusions at the
lateral compartment and underneath the quadriceps tendon. Trace effusion in
the medial compartment.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: ___ year old woman with back pain and bacteremia,// rule out
osteo. gfr 34 rule out osteo. gfr 34
TECHNIQUE: Sagittal imaging was performed with T2, T1, and technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of ___
contrast agent.
COMPARISON: Prior CT ___ dated ___. CT abdomen/pelvis dated ___.
FINDINGS:
Alignment is anatomic. Focal T1 and T2 hyperintensity in the L4 vertebral
body and L5 pars interarticularis likely represent fatty replacement of the
marrow. Additionally, there is slight loss of the L3-L4 and L4-L5
intervertebral disc signal intensity, representing desiccation due to
degenerative changes. Otherwise, the vertebral body and intervertebral disc
signal intensity appear normal. Furthermore, there is no evidence of osseous
erosion appreciated. The spinal cord appears normal in caliber and
configuration with the conus medullaris terminating at T12-L1. There is no
evidence of critical spinal canal or neural foraminal narrowing. However,
multilevel degenerative changes are seen and are as described below.
T12-L1: Mild right neural foraminal narrowing due to a mild disc bulge. No
significant spinal canal or left neural foraminal narrowing.
L1-L2: No significant degenerative changes noted.
L2-L3: Mild spinal canal and bilateral neural foraminal narrowing due to
osteophyte formation, ligamentum flavum thickening, and mild disc bulge.
L3-L4: Mild bilateral, left greater than right, neural foraminal narrowing due
to osteophyte completion and ligamentum flavum thickening.
L4-L5: Mild bilateral foraminal narrowing due to osteophyte formation and
ligamentum flavum thickening.
L5-S1: Moderate left neural foraminal narrowing, mild right neural foraminal
narrowing, and mild spinal canal narrowing due to disc bulge and osteophyte
formation.
There is mild STIR hyperintensity representing prevertebral edema from L3
through the sacrum. The edema is most prominent anterior to L5, measuring up
to 5 mm in diameter (series 3, image 7). No abnormal postcontrast
enhancement.
IMPRESSION:
1. No intervertebral disc or vertebral body signal changes or erosions to
suggest discitis osteomyelitis.
2. Mild-to-moderate multilevel degenerative changes, most prominent at L5-S1
where subsequently there is moderate left neural foraminal narrowing.
3. Mild prevertebral edema from L3 through the sacrum, most prominent anterior
to L5, of uncertain etiology.
Radiology Report
EXAMINATION: Ultrasound-guided right knee aspiration.
INDICATION: ___ year old woman with RA presenting with r knee effusion that
could not be drained by rheum// rule out septic joint
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small right
knee joint effusion. A suitable target in the deepest pocket in the lateral
aspect of the joint was selected for aspiration.
PROCEDURE: Ultrasound guided right knee aspiration
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.
Approximately 6 cc of clear straw-colored joint fluid was aspirated from the
right knee.
The patient tolerated the procedure well without immediate complication.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
-Small right knee joint effusion.
-Technically successful ultrasound-guided right knee joint aspiration.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with heart failure// evaluate for volume
overload
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph of the chest performed 2 weeks prior
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Lung volumes have
improved in the interim with interval improvement in right lung base
opacities. No evidence of pneumothorax. Small right pleural effusion is
unchanged. Mild pulmonary vascular congestion is persistent.
IMPRESSION:
Stable mild pulmonary vascular congestion. Improved lung volumes.
Persistent small right pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, N/V
Diagnosed with Acute kidney failure, unspecified, Enterocolitis d/t Clostridium difficile, not spcf as recur, Personal history of other venous thrombosis and embolism, Long term (current) use of anticoagulants
temperature: 98.4
heartrate: 90.0
resprate: 18.0
o2sat: 95.0
sbp: 134.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ___ y/o F with PMHx of HFrEF, VT treated with
ATP and ICD, CAD s/p PCI, afib on Coumadin, poorly
controlled IDDM2, HTN, HLD, DVT, depression, RA, hypothyroidism,
OSA, recurrent C. difficile, nonhealing left foot ulcer status
post debridement and VAC placement, osteomyelitis s/p 6 week
course of IV abx in ___, and most recent admission for GBS
bacteremia thought to be from L foot on CFTX until ___, now
sent
back from rehab with N/V/D, weakness, and ___.
# Enterococcal UTI and BSI:
# History of Vtach and EF 15% s/p ICD placement
# Lumbar back pain
The patient has denied urinary symptoms but presented with
nausea
and ___. Her urine and blood cx now speciated as the two same
species of enterococcus (+VRE) with additional CoNS in her
blood.
She was started on daptomycin and since then has been afebrile
without significant leukocytosis. The ID team felt that she most
likely had a polymicrobial urine infection that then seeded her
blood. There were concerns for septic right knee given
pain/swelling and decreased active ROM but the aspiration was
unremarkable. TEE did not show any vegetations. Spinal MRI was
performed due to ongoing lower back pain but showed no evidence
of infectious process. ID recommended continuing daptomycin
until
___. She will continue prophylactic po vancomycin for c
diff
for one week beyond that (end date: ___. CK levels were
checked
and WNL.
#Toxic Metabolic Encephalopathy (resolved)
Noted on ___ to be oriented only to person and very somnolent.
Refusing most medications. Did have severe pain overnight for
which she received 5 mg oxycodone. Also has CKD and is on 400 mg
gabapentin at night, though this is a home medication. Suspect
hospital delirium I/s/o ongoing infection vs medication effects
# R knee pain and effusion
C/f septic joint given reduced active and passive ROM but pt
seen
by rheum and they felt OA ___ cyst are more likely.
Aspiration was attempted but not successful so it was done by
___.
Gram stain with only 3% polys indicating that pt did not have a
septic knee
# NVD (improved)
# C diff colonization
Given recent admission for bacteremia and current abx course,
this was initial concern for c.diff. She was started on PO
vancomycin on admission. C.diff PCR positive; toxin has returned
negative. On further history, it appears that she did not have
much diarrhea prior to presentation, and she remains constipated
here. Vanc dose has been decreased to BID for c.diff ppx with
plans to continue until 1 week after daptomycin end date of ___.
# ___:
Baseline Cr ~1.6, 2.3 on this presentation. Suspect most likely
prerenal in the setting of NVD. FeNa is borderline (~1%). Cr
improved with IVFs given on admission initially, then started to
uptrend again, s/p 1 unit of pRBCs with improvement in Cr. On
the
days leading up to discharge, her Creatinine was 1.2-1.3.
# Anemia: Normocytic, at recent baseline and without evidence of
active bleeding. Iron studies c/w ACD. S/p 1 unit of pRBCs with
appropriate bump in H/H.
# Recent GBS Bacteremia: Thought to be from L foot. Pt was on
CFTX until ___, now complete.
# Atrial Fibrillation
# Coagulopathy
On metoprolol for rate control, coumadin for anticoagulation.
INR
supratherapeutic on presentation, presumably ___ recent poor
nutritional status and antibiotic administration. It was
restarted on ___ for INR 2.2 at 2 mg daily. Levels should be
checked at rehab and she should be dosed for a goal INR of ___.
# DMII c/b Neuropathy and Retinopathy: With hypoglycemia on
admission. We continued ___ and ___ and held metformin
while she was here. She has been on a diabetic diet.
# CAD: Denies chest pain. ECG without ischemic changes. Tn
mildly
elevated but stable. Low suspicion for ACS. We continued ASA,
metoprolol, and rosuvastatin
# Acute sCHF:
EF 15%. Pt is complaining of orthopnea, with JVP to earlobe and
new pleural effusions noted on ___ CXR. This likely occured
i/s/o fluid resuscitation for ___ and ___ home Lasix. Now
s/p
20 mg IV Lasix (home dose is 20 mg po Lasix) on ___. She is
discharging on her home furosemide.
#Sinus tachycardia up to 120s. Suspect HR was elevated due to
mild respiratory distress from mild pulmonary vascular
congestion
and small right pleural effusion based on CXR ordered ___.
Improved with treatment of her infections.
# L heel ulceration: Foot films with soft tissue defect without
evidence of osseous erosion. Wound care was provided and she was
started on ascorbic acid ___ mg BID
# Depression: continued home bupropion, duloxetine
# Hypothyroidism: continued levothyroxine
# Transaminitis:
Mild and now resolved. Hepatitis serologies negative. Likely
NASH.
# Pancreatic Hypodensities: stable from prior, concern for ___,
___ need outpt f/u. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malpositioned HD line
Major Surgical or Invasive Procedure:
R IJ tunneled HD line exchange ___
History of Present Illness:
The patient is a ___ with PMH of ESRD ___ to scleroderma renal
crisis on HD (___), rheumatologic overlap syndrome,
hepatitis C, and history of PEs on Coumadin, who presents with a
malpositioned HD line, also with concern for possible line
infection with plan for ___ exchange. Pt states that she last had
dialysis on ___, and since then her tunneled HD line in
her right IJ has been particularly painful, worse with movement.
She subsequently went to dialysis that day, was found to have a
dislodged HD line with exposed cuff, HD was not performed, and
she was referred to the emergency department. Patient states
that
she has had some low-grade fevers, has been feeling more
fatigued, and has had some weakness. She denies cough, nausea,
vomiting, diarrhea, dysuria.
In the ED:
Initial vital signs were notable for:
T 98.7, HR 76, BP 136/67, RR 18, O2 100%RA
Exam notable for:
HD line appears malpositioned w/ sutures broken, slightly pulled
out with surrounding erythema, however no expressed purulence
Labs were notable for:
WBC 2.7 (baseline 2.5-4.5), Hgb 9.6 (basline 7.5-9.5), Plt 64
(60s-low 100s)
Bicarb 18, BUN 44, Cr 4.9
Phos 7.2, Ca 7.8
___ 32.7 PTT 49.5 INR 3.0
UA 100 protein otherwise bland
Studies performed include:
CXR ___: No acute cardiopulmonary abnormality.
Patient was given:
___ 23:24PO/NGCaptopril 25 mg
___ 08:59PO/NGCaptopril 25 mg
___:59PO/NGHydroxychloroquine Sulfate 300 mg
___ 08:59PO/NGNephrocaps 1 CAP
___ 11:30PO/NGCalcium Acetate 667 mg
___ 16:11PO/NGCaptopril 25 mg
___ 16:11IVVancomycin 1gm
___ 16:11IVCefTRIAXone 2 gm
Consults:
___ - Right IJ tunneled dialysis catheter with exposed cuff and
mild erythema/tenderness to palpation - will plan for tunneled
dialysis catheter exchange, resite, or new catheter placement
tentatively on ___. NPO at midnight on ___. Please hold
coumadin.
Renal - No urgent indication for HD today. Will check labs again
when admitted to the floor, plan for dialysis ___ after ___
re-seats HD catheter. Reevaluation: some increasing redness
around site of line c/f possible infection, would recommend ___
pull today and abx w/ vanc/ctx.
Vitals on transfer:
T 99.0, BP 152/77, HR 80, RR 18, 95% RA
On arrival to the floor the pt confirms the above history. She
says she is thirsty, but has no pain.
ROS as above - also notable for weight loss and poor appetite,
with early satiety for months. She is seeing GI soon to discuss
abnormal findings of a barium swallow which showed findings
consistent with scleroderma. She also had a fall recently, and
is working with ___.
Past Medical History:
hepatitis C
anemia
rheumatologic overlap syndrome with features of:
cutaneous discoid lupus
limited scleroderma (positive anticentromere ab)
Sjogren's syndrome
Raynauds
Scleroderma Renal Crisis
Social History:
___
Family History:
The patient's sister recently died from a stroke. She had a
heart condition, brother has thyroid disease. She had two sons,
one committed suicide, the other one healthy.
Physical Exam:
ADMISSION EXAM
VITALS: T 99.0, BP 152/77, HR 80, RR18, 95% RA
GENERAL: Alert and interactive. In no acute distress. Speaking
very softly. Cachectic.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
Dry MM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Scab over sacrum which is TTP but without erythema or
drainage.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Tunneled dialysis line in R side
with
erythema, no drainage, and non TTP. Vitiligo.
NEUROLOGIC: grossly intact by observation
DISCHARGE EXAM
___ ___ Temp: 97.8 PO BP: 132/77 L Lying HR: 73 RR: 18 O2
sat: 100% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress. Speaking
very softly. Cachectic.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
Dry MM.
Neck: R IJ tunneled line placed, still has some tenderness to
palpation overlying line, no surrounding erythema.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Scab over sacrum which is TTP but without erythema or
drainage.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Tunneled dialysis line in R side
with
erythema, no drainage, and non TTP. Vitiligo.
NEUROLOGIC: grossly intact by observation
Pertinent Results:
ADMISSION LABS
___ 08:00PM BLOOD WBC-2.7* RBC-3.14* Hgb-9.6* Hct-30.9*
MCV-98 MCH-30.6 MCHC-31.1* RDW-17.0* RDWSD-61.5* Plt Ct-64*
___ 08:19PM BLOOD ___ PTT-49.5* ___
___ 08:00PM BLOOD Glucose-93 UreaN-44* Creat-4.9* Na-141
K-4.4 Cl-107 HCO3-18* AnGap-16
___ 08:00PM BLOOD Calcium-7.8* Phos-7.2* Mg-2.0
INTERVAL LABS
___ 05:19AM BLOOD ALT-87* AST-114* AlkPhos-101 TotBili-0.5
DISCHARGE LABS
___ 05:23AM BLOOD WBC-3.1* RBC-2.98* Hgb-9.3* Hct-29.0*
MCV-97 MCH-31.2 MCHC-32.1 RDW-17.0* RDWSD-60.0* Plt Ct-66*
___ 05:23AM BLOOD ___ PTT-38.0* ___
___ 05:23AM BLOOD Glucose-96 UreaN-59* Creat-5.7* Na-144
K-5.3 Cl-111* HCO3-16* AnGap-17
___ 05:23AM BLOOD Calcium-8.1* Phos-7.3* Mg-2.0
___ 03:15PM BLOOD Vanco-21.4*
MICRO
Time Taken Not Noted Log-In Date/Time: ___ 9:02 pm
BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING/REPORTS
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Dialysis access report ___: Successful placement of right
internal jugular vein Glidepath 19cm tunneled hemodialysis
catheter using same venotomy site. Fluoroscopy confirms good
position with no complications. Permanent images are recorded.
The catheter is ready for use.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with fever, ESRD on dialysis// evaluate for pna,
acute process
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Right-sided dual lumen central venous catheter tip terminates in the SVC/right
atrial junction. Heart size is normal. Mediastinal and hilar contours are
unremarkable. Pulmonary vasculature is not engorged. Lungs are clear. No
pleural effusion or pneumothorax is present. No acute osseous abnormalities
visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Hemodialysis
Diagnosed with Oth complication of vascular prosth dev/grft, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 98.7
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old female with PMH of ESRD ___ to
scleroderma renal crisis on HD (___), rheumatologic overlap
syndrome, hepatitis C, history of PEs on Coumadin, failure to
thrive who presented from HD with dislodged HD line with exposed
cuff, also with concern for possible line infection, underwent
___ tunneled HD line exchange, was initially on vancomycin and
ceftriaxone for a possible line infection. Subsequently
underwent successful HD. Due to lower concern for tunneled HD
line infection with negative blood cultures, CTX was
discontinued. Per renal will received one more dose of
vancomycin at HD on ___ at her outpatient dialysis center.
#Malpositioned HD line - Patient initially presented from HD on
___ found to have dislodged tunneled right IJ HD line, with
exposed cuff. She underwent ___ tunneled HD line exchange, with
new right IJ tunneled HD catheter placed. She subsequently
underwent successful dialysis on ___.
#Possible HD line infection - On admission, there was initial
concern for possible HD line infection. She had subjective
low-grade fevers, with surrounding erythema at exit site of
tunneled HD line, in addition to tenderness to palpation around
HD line. Per initial renal recommendations, she was started on
vancomycin and ceftriaxone. Blood cultures on admission however
remain no growth to date at discharge, and suspicion for HD line
infection was subsequently low. Decision was made in
consultation with renal to dprovide short course of vancomycin
at dialysis. Ceftriaxone was discontinued, and per renal
recommendations, plan to receive 2 additional doses of
vancomycin at next dialysis sessions on ___ and ___.
#ESRD on HD (___) - Patient with history of ESRD ___
scleroderma renal crisis and rheumatologic overlap syndrome
recently initiated on HD. Tunneled R IJ line was replaced per
above and was continued on nephrocaps and calcium acetate 667mg
PO TID daily.
#?UTI - Previously with CTX and cefepime resistant E. Coli UTI,
urine culture on admission with E. Coli, however UA was overall
bland. Initially on CTX for possible line infection per above,
however did not treat for a CTX resistant E. Coli UTI given
thought to more likely be colonized as she was also
asymptomatic.
#APLS
#Hx PE on coumadin - Pt with history of PE and anti-phospholipid
syndrome, on warfarin. Goal INR ___. With supra-therapeutic INR
on admission likely in setting of severely poor PO intake and
vitamin K deficiency. Anticoagulation was held during
hospitalization in the setting of HD line exchange. INR on
discharge 1.5, given history of remote PE will give warfarin 5mg
x1, with plan to re-start home regimen warfarin 5mg 2X/week
(Mo/TH) and 2.5mg 5X/Week ___, We, Fr, Sa). Confirmed to
follow-up with ___ and ___ for next INR check at
___ on ___.
#Pancytopenia - History of pancytopenia, likely in setting of
rheumatologic overlap syndrome and ESRD. WBC with baseline
2.5-3.5, Hgb with baseline 7.5-9.5, Plt with baseline ___
100s. Currently, WBC 3.4, Hgb 9.5, Plt 79, all within baseline
range. On Aranesp as outpatient. Also likely in setting of known
hepatitis C with cirrhosis, also on hydroxychloroquine. Can
consider outpatient hematology/oncology referral given weight
loss per below with failure to thrive for hematologic malignancy
work-up.
#Severe malnutrition- With 22 lb weight loss over the last 5
months, thought to be secondary to uremia during last admission
as patient recently started HD. She is seeing a ___ and
was recently started on megestrol acetate. With poor appetite
and weight loss even prior to HD, has been noted to previously
have dysphagia with abnormal peristalsis. Nutrition was
consulted. Will make transitional issue to make sure patient is
up to date on all age appropriate cancer screenings and
additional malignancy workup as indicated. Would also have PCP
consider switching megace to merenol given her prothrombotic
state and interaction of megace with warfarin.
=============== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right hand numbness and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old right-handed woman who
presents with three episodes of right hand "heaviness" starting
at 10 AM one day prior to admission (about 25 hours prior to
this
CODE STROKE). She has never had these symptoms before. She has a
prior history of two prior ischemic strokes (with left facial
droop, left arm weakness, dysarthria and confusion per her
daughter and granddaughter) and significant autonomic
instability
(HR and BP changes) and currently is on dipyramidole only as an
antithrombotic (no aspirin per the patient) and no
antihypertensive therapy due to recurrent syncope. She describes
three paroxysmal five minute episodes at 10AM yesterday,
sometime
yesterday evening, and 10AM today of right hand "heaviness" with
some numbness in her fingers and possibly the dorsum of her hand
(possibly palmar side as well) up to at least the wrist but
possibly up to the elbow. She describes that her fingers were
difficult to move. She describes this as "the arm felt dead."
She
thinks that she may have been somewhat clumsy as she reached
down
to pick something up and missed. She denies any headache, neck
pain, or any other symptoms with this. She seems frustrated when
asked to describe the episode further, but her daughters
describe
that during this time she seemed somewhat more confused (more
forgetful) and at times seem to have a "glazed look" in her
eyes.
She had no frank behavioral or speech arrests, convulsions, or
loss of consciousness. They think she has been more "off" during
the past 2 days, but overall has been "off" since her last
stroke
in ___. (She was treated for both strokes at ___
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Endorses "heaviness" with difficulty moving fingers and with
some
numbness.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
[] Neurologic - Ischemic stroke (unknown location, but p/w left
face and arm weakness, dysarthria, confusion; evaluated and
treated at ___, received IV tPA)
[] Cardiovascular - CAD, HTN, HL, Syncope, Autonomic instability
(HR and BP)
[] Oncologic - Metastatic breast cancer (initially left breast,
then right breast and lung, likely thyroid)
[] Gastrointestinal - GERD
[] Endocrine - Hyperparathyroidism
Social History:
___
Family History:
No stroke, no seizures, no brain malignancies, no
headaches, no demyelination, no other neurologic disease.
Possible HTN (mother).
Physical Exam:
VS T: 97.4 HR: 62 BP: 195/100 RR: 16 SaO2: 96% RA
General: NAD, lying in bed comfortably, pleasant elderly woman.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no cervical artery bruits
Cardiovascular: RRR, no M/R/G
Pulmonary: No crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: Dry excoriated skin
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained
when recalling months forwards backwards. Recalls a coherent
history. Structure of speech demonstrates fluency with full
sentences (but with some limitation in vocabulary), intact
repetition, and intact verbal comprehension. Content of speech
demonstrates intact high frequency but impaired low frequency
naming (unable to name hammock) and no paraphasias. Normal
prosody. No dysarthria. Hand-tool apraxia with combing hair,
brushing teeth, and unable to perform hammering of nail. No
evidence of hemineglect. No left-right agnosia. Some
perservation
with speech and motor tasks.
- Cranial Nerves - [II] PERRL 2.5->1 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
- Motor - Diminished first dorsal interosseous, thenar and
hypothenar eminence and EDB bulk. No pronation, no drift. No
tremor or asterixis. No myoclonus. With motor tasks,
perseverates
with some commands (will continue action with the initial limb
that she was tested with)
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5-] [L 5-]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L 5]
Interosseus [C8] [R 4+] [L 4+]
Abductor Digiti Minimi [C8] [R 4+] [L 4+]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5-] [L 5-]
Extensor Digitorum Brevis [L5] [R 4+] [L 4+]
Flexor Digitorum Brevis [S1] [R 5] [L 5]
- Sensory - Patchy pin sensory diminishment in both arms and
legs, no clear distribution. Diminished proprioception at both
first toes bilaterally. Has difficulty with point localization
in
both arms.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 3 0
R 3 3 3 3 0
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Deferred.
Pertinent Results:
___ 09:35PM CK(CPK)-102
___ 09:35PM CK-MB-3 cTropnT-<0.01
___ 08:54PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 08:54PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
___ 12:13PM GLUCOSE-115* NA+-143 K+-4.1 CL--99 TCO2-29
___ 12:00PM CREAT-1.1
___ 12:00PM UREA N-17
___ 12:00PM estGFR-Using this
___ 12:00PM ALT(SGPT)-11 AST(SGOT)-19 ALK PHOS-94
___ 12:00PM ALBUMIN-4.3
___ 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:00PM WBC-5.2 RBC-4.26 HGB-13.5 HCT-41.7 MCV-98#
MCH-31.7 MCHC-32.4 RDW-13.0
___ 12:00PM PLT COUNT-203
___ 12:00PM ___ PTT-28.8 ___
MRI
There are several small cortical infarctions detected in the
left
motor cortex. These may represent small embolic infarctions.
There is no
evidence of hemorrhage. No other areas of new infarction are
detected. Again
seen are multiple bilateral lacunar infarctions in the caudate,
putamen, and
globus pallidus. Again seen is extensive periventricular white
matter signal
abnormality suggesting chronic small vessel ischemia.
CTA
1. Two lacunar infarcts in the right caudate head and left
centrum semiovale,
not present on CT of ___. No acute intracranial
abnormality.
2. Occluded left vertebral artery with reconstitution in V3,
unknown
chronicity.
3. No aneurysm greater than 3 mm.
4. Enlarging pulmonary masses is measuring up to 2.7 cm,
consistent with
metastatic disease from known breast CA.
5. Focal lucent lesion in the right lamina of C6 could represent
osseous
metastasis.
6. Evidence of pulmonary hypertension as described above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dipyridamole 75 mg PO BID
2. Atorvastatin 40 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left sided infarcts
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Some difficulty with naming, full strength, decreased
proprioception on the right hand
Followup Instructions:
___
Radiology Report
HISTORY: Left-arm and intermittent right arm weakness.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Subsequently rapid axial imaging was performed from the
aortopulmonary window through the head during infusion of 70 cc Omnipaque
intravenous contrast material. Images were processed on a separate
workstation with display of curve reformats, 3D volume rendered images, and
maximum intensity projection images.
COMPARISON: CT head, ___. CT torso from ___, ___.
FINDINGS:
NECT-Head. There is no hemorrhage, edema, mass effect, or evidence of
territorial infarction. However there are two new subcentimeter hypodensities
in the right caudate head and left centrum semiovale (2:15, 17). The
ventricles and sulci are prominent, consistent with global atrophy. The basal
cisterns are patent and gray-white matter differentiation is preserved. The
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
CTA: The anterior and posterior circulations are patent. There is no aneurysm
greater than 3 mm, dissection, or intracranial stenosis.
The left vertebral artery is occluded throughout its course with
reconstitution in the V3 segment. The carotid arteries and their major
branches are patent with no evidence of stenosis.
The main, left, and right pulmonary arteries are all markedly dilated. In
addition, the visualized azygos is also dilated. There are numerous lung
nodules consistent with known metastatic disease. The largest in the left
upper lobe and measures 2.7 x 2.0 cm, enlarged from CT torso of ___
when measured 1.9 x 1.5 cm. 12 mm thyroid nodule is slightly larger when
compared to an most recent CT torso (3:94).
Incidental note is made of a tiny lytic leion in the right lamina of C6
(3:127).
IMPRESSION:
1. Two lacunar infarcts in the right caudate head and left centrum semiovale,
not present on CT of ___. No acute intracranial abnormality.
2. Occluded left vertebral artery with reconstitution in V3, unknown
chronicity.
3. No aneurysm greater than 3 mm.
4. Enlarging pulmonary masses is measuring up to 2.7 cm, consistent with
metastatic disease from known breast CA.
5. Focal lucent lesion in the right lamina of C6 could represent osseous
metastasis.
6. Evidence of pulmonary hypertension as described above.
Radiology Report
MR HEAD, ___
HISTORY: Episodes of right hand heaviness.
Sagittal imaging was performed with short TR, short TE spin echo technique.
Axial imaging was performed with ___ TR, long TE fast spin echo,
gradient echo, and diffusion technique. Comparison to a head CT of ___.
FINDINGS: There are several small cortical infarctions detected in the left
motor cortex. These may represent small embolic infarctions. There is no
evidence of hemorrhage. No other areas of new infarction are detected. Again
seen are multiple bilateral lacunar infarctions in the caudate, putamen, and
globus pallidus. Again seen is extensive periventricular white matter signal
abnormality suggesting chronic small vessel ischemia.
CONCLUSION: Several small left motor cortex infarctions. No evidence of
hemorrhage.
Again seen are extensive lacunar infarctions bilaterally.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT ARM WEAKNESS
Diagnosed with MUSCSKEL SYMPT LIMB NEC, TRANS CEREB ISCHEMIA NOS, PERSONAL HISTORY OF TIA, AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS
temperature: 97.4
heartrate: 62.0
resprate: 16.0
o2sat: 95.0
sbp: 195.0
dbp: 100.0
level of pain: 0
level of acuity: 1.0 | Transtition Issues: Echo as an outpatient with bubble. Blood
pressure management.
This is an ___ year old woman with a history of ischemic
strokes, HTN, HL, metastatic breast cancer (to the lung and
possibly thyroid), and recurrent syncope who presents with right
hand heaviness, found to have multiple left cortical infarcts on
MRI.
NEURO: The patient was admitted to the stroke service. Her
stroke risk factors were checked including LDL (53) and A1c
(5.4%). Her atorvastatin was continued. An echocardiogram was
not done due to a holiday schedule and this should be done as an
outpatient. The cause of your stroke was likely embolic due to
an increased propensity towards blood clots given metastatic
cancer. We have augmented her antiplatelet regimen by switching
to aggrenox.
CARDS: THe patient was monitored on telemetry and no events were
noted. Cardiac enzymes were negative. The patient had very
elevated blood pressures (180-190s at times). On amilodipine 5mg
the systolic blood pressure then dropped to the ___ so no
further blood pressure control was attempted. The patient
reports this being a problem in the past.
ONC: Patient has known metastatic breast cancer. CT showed a
likely metastatic lesion at C6 as well as lung nodules.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL =53 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
J-tube leakage
Major Surgical or Invasive Procedure:
J-tube replacement on ___
History of Present Illness:
___ yo male hx substance use disorder, paroxysmal AV block s/p
PPM, chronic abdominal pain, TEVAR, HCV, esophageal diversion
for
perf s/p esophagectomy (___) and J-tube, fistula with
pectoral flap, alcohol use disorder who presents today with
J-tube leakage.
J-tube (replaced ___ by ___ presents with leakage around J
tube site and abdominal pain. Pt states he had pain after the J
tube was replaced but figured it would get better. He says it
continued to increase in pain after he left the hospital, pain
remains located in LUQ around J tube site. He also states any
use
of his J tube resulted in leakage (uses jevity for nutrition.)
Of note pt is able to tolerate drinking clear liquids normally,
though he did say he noticed when he tried to drink coffee it
spilled out around the J tube. Does drink fifth of vodka daily.
He states he has had seizures before from alcohol withdrawal.
Past Medical History:
EtOH use disorder and opiate dependence
Asthma
HTN
CVA
Chronic pain
Hep C,
Esophageal stricture/ulcers s/p multiple dilations, complicated
by esophageal perforation w/ repair; complicated by
Esophagocutaneous fistula
Seizure disorder
Nonischemic cardiomyopathy
Depression
___ on CKD
Delirium
Complete heart block s/p PPM, hx pacemaker malfunction
PAF
Necrosis of the gastric conduit tip and leak
Acute blood loss anemia
Severe malnutrition
Pneumonia
PSH: hip replacement, knee surgery, shoulder surgery, vascular
surgery on R arm
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
===============
VITALS: reviewed in OMr
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation aside from left lower abdomen. J tube on left side
with
surrounding erythema. No purulent drainage noted or pustules.
Skin around j tube with increased warmth and slightly indurated
EXTREMITIES: No clubbing, cyanosis, or edema aside from right
hand being more swollen.
SKIN: Warm. Cap refill <2s. Rash as above.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation.
DISCHARGE EXAM:
===============
VS: Temp: 98.2 (Tm 98.2), BP: 122/76 (122-172/76-87), HR: 74
(69-74), RR: 20 (___), O2 sat: 97% (97-99), O2 delivery: Ra
GENERAL: Alert and interactive. NAD.
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
CHEST: Gauze over neck. Pacer and pec flap not visualized as
under dressing. dressing cdi.
LUNGS: Lungs clear to auscultation bilaterally in ant fields w
nl WOB
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation aside from left lower abdomen. Replaced J tube on left
side covered with dressing from ___ procedure.
EXTREMITIES: wwp, no edema, erythema resolved from R hand.
NEUROLOGIC: AOx3, face symmetric, moving all 4 limbs
spontaneously.
Pertinent Results:
ADMISSION LABS:
================
___ 04:29PM BLOOD WBC-15.1* RBC-3.12* Hgb-10.4* Hct-32.0*
MCV-103* MCH-33.3* MCHC-32.5 RDW-15.6* RDWSD-58.4* Plt ___
___ 04:29PM BLOOD Glucose-87 UreaN-17 Creat-0.8 Na-133*
K-4.0 Cl-95* HCO3-15* AnGap-23*
___ 04:29PM BLOOD ALT-48* AST-80* AlkPhos-194* TotBili-0.4
___ 04:29PM BLOOD Albumin-3.9 Calcium-8.2* Phos-3.4 Mg-2.1
PERTINENT INTERVENING LABS:
==========================
___ 06:38AM BLOOD ALT-18 AST-13 AlkPhos-119 TotBili-0.2
___ 07:15AM BLOOD HIV Ab-NEG
MICRO:
======
___ Blood Culture x 2: No growth
IMAGING
========
-___ CT abdomen and pelvis
1. Distended bladder, which should be correlated for urinary
retention or bladder outlet obstruction. No other acute
abnormalities within the abdomen or pelvis.
2. Apparent wall thickening affecting the hepatic flexure, which
may be due to underdistention, and should be correlated with any
recent colonoscopy.
3. Unchanged heterogeneous sclerosis of the right femoral head,
compatible with avascular necrosis.
4. Unchanged moderate loss of height and defect in the L1
vertebral body with mild retropulsion.
5. Atelectasis at the lung bases with centrilobular nodules of
the lingula and left lower lobe which could be sequela of
aspiration.
-___ CXR
Left lung base opacity which could represent infection or
aspiration.
-___ Right Upper Extremity Venous Ultrasound
1. Deep vein thrombosis of duplicated brachial veins.
2. An avascular elongated soft tissue mass along the midportion
of the right upper arm measuring 1.0 x 0.5 x 0.7 cm, may
represent scar tissue or a reactive lymph node.
-___ X-ray portable abdomen
IMPRESSION:
Positioning of new jejunostomy tube is not fully assessed on
this single view but it has changed orientation somewhat and it
is possible that it makes a tight bend. No evidence of
obstruction or free air.
-___ J-tube check/replacement
1. Existing J tube completely clogged
2. Replacement with a new 20 ___ jejunal tube
DISCHARGE LABS:
================
None clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. amLODIPine 5 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. LORazepam 1 mg PO BID:PRN anxiety
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*11
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tab-cap by mouth once a day Disp
#*30 Tablet Refills:*11
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*11
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
6. amLODIPine 5 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. LORazepam 1 mg PO BID:PRN anxiety
9. Montelukast 10 mg PO DAILY
10. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
------------------
Right upper extremity deep venous thrombosis
___ J-tube cellulitis
J-Tube malfunction
Alcohol withdrawal
Aspiration pneumonia
SECONDARY DIAGNOSIS
--------------------
Hypertension
Transaminase elevation
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old man with right hand swelling// R upper extremity DVT?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Ultrasound from ___
FINDINGS:
Occlusive thrombus is seen at the bilateral proximal brachial veins, which are
noncompressible. 1 of the duplicated brachial veins demonstrate persistent
occlusive thrombus through the midportion.
There is normal flow with respiratory variation in the right subclavian veins.
The right internal jugular, and axillary veins are patent, show normal color
flow, spectral doppler, and compressibility. The right basilic, and cephalic
veins are patent, compressible and show normal color flow.
There is an avascular elongated soft tissue mass along the midportion of right
upper arm measuring 1.0 x 0.5 x 0.7 cm.
IMPRESSION:
1. Deep vein thrombosis of duplicated brachial veins.
2. An avascular elongated soft tissue mass along the midportion of the right
upper arm measuring 1.0 x 0.5 x 0.7 cm, may represent scar tissue or a
reactive lymph node.
NOTIFICATION: The findings were discussed with ___ by ___,
M.D. on the telephone on ___ at 12:00 pm, 10 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: Abdominal radiograph, single AP view.
INDICATION: Jejunostomy tube placement. Recently placed. Worsening
abdominal pain and sluggish flushing of the feeding tube.
COMPARISON: A CT is available from ___.
FINDINGS:
Jejunostomy tube projects over the left mid abdomen. On the recent CT is
adopted a retrograde course an terminated in the proximal third portion of the
duodenum. On this study, tube seems to initially head and the same direction
but then turns back in terminates in the left upper quadrant. Its course is
not fully assessed but the possibility that it may be kinked in the third
portion of the duodenum could be considered. Lower thoracic stent graft
visualized with clips. Inferior vena cava filter in left hip hemiarthroplasty
also again visualized. Bowel gas pattern is unremarkable. Stomach does not
appear distended. No dilated loops of large or small bowel. Patchy mild
quantities of stool throughout the colon, including the rectum. No evidence
of free air.
IMPRESSION:
Positioning of new jejunostomy tube is not fully assessed on this single view
but it has changed orientation somewhat and it is possible that it makes a
tight bend. No evidence of obstruction or free air.
RECOMMENDATION(S): If there is ongoing clinical concern regarding jejunostomy
tube function, then injection under fluoroscopy may be helpful to assess
further.
Radiology Report
INDICATION: ___ year old man with Esophageal perforation currently maintained
with a ___ J tube recently changed now with significant resistance with
flushing.// Assess for occlusion/kinking
COMPARISON: Multiple prior exchanges
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: 50 mcg of fentanyl
MEDICATIONS: As above
CONTRAST: 30 ml of OPTIRAY contrast
FLUOROSCOPY TIME AND DOSE: 9 min, 109 mGy
PROCEDURE: 1. Exchange of a jejunostomy tube.
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 upper abdomen and tube site was prepped and draped in the usual
sterile fashion.
The jejunostomy tube was noted to be clogged. No contrast could be injected.
A Glidewire was attempted to be inserted, however this was unsuccessful due to
kinking of clogging. The G-tube was removed and a new Kumpe catheter was
placed. The Kumpe catheter was navigated through the jejunum to a antegrade
jejunal loop and then distally. Then, a Glidewire was introduced into the
Kumpe catheter and the Kumpe the was removed. A new 20 ___ mic J tube was
then advanced over the Glidewire and into the jejunum.
FINDINGS:
1. Existing J tube completely clogged
2. Replacement with a new 20 ___ jejunal tube
IMPRESSION:
Successful exchange of a jejunal tube with a new 20 ___ MIC jejunal tube.
RECOMMENDATION(S): Aggressive flushing regimen to prevent buildup of debris
in the jejunal tube.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Jtube eval
Diagnosed with Alcohol dependence with intoxication, unspecified
temperature: 96.0
heartrate: 96.0
resprate: 20.0
o2sat: 96.0
sbp: 117.0
dbp: 88.0
level of pain: 9
level of acuity: 3.0 | ___ yo male hx substance use disorder, paroxysmal AV block s/p
PPM, chronic abdominal pain, TEVAR, HCV, esophageal diversion
for
perf s/p esophagectomy (___) and J-tube, fistula with
pectoral flap, alcohol use disorder who presented with
J-tube leakage with erythema surrounding it concerning for
cellulitis, now with RUE DVT on apixaban.
ACTIVE ISSUES
--------------
# PERISTOMAL CELLULITIS
CT abdomen/pelvis on ___ was not concerning for intraabdominal
infection, however patient received one dose of ceftriaxone and
metronidazole in the ED. WBC elevated likely in setting of
cellulitis around J-tube, and was started on vancomycin on ___.
His antibiotic course was as follows ___ Unasyn (to also
treat concomitant aspiration pneumonia) -> conversion to
augmentin ___ which was not tolerated due to vomiting -> IV
ceftriaxone/metronidazole given unasyn shortage, end date ___.
The erythema lessened with antibiotics, with persistent erythema
directly around the J-tube likely secondary to irritation.
# LINGULAR/LLL PNEUMONIA
Had left lung base opacity on CXR on admission, with a dry
cough,
and shortness of breath. He was without hypoxia, breathing
comfortably on room air, intermittently had shortness of breath.
Likely resolved; was treated with antibiotics given for
concomitant cellulitis (see above).
# VOMITING/REGURGITATION
# ESOPHAGEAL/ABDOMINAL DISCOMFORT
# ESOPHAGEAL PERFORATION S/P ESOPHAGECTOMY AND FISTULA
# J TUBE LEAKING S/P REPLACEMENT
Hx of esophageal perforation s/p esophagectomy ___ with complex
surgical course and recovery from this, most recently s/p ___
closure esophagocutaneous fistula. A small pin point fistula
persists near upper left pec that is healing well. Pt now
reports taking 30% of his nutrition by mouth and 70% though
J-tube on jevity. He has chronic pain in his abdomen and will
have emesis/regurgitation at times. He remains at risk for
aspiration and has pain with swallowing. J tube was leaking on
admission and had been replaced on ___ and then again on ___
after it was found to have been clogged/kinked, which may have
exacerbated his pain. During admission, pt had worsening
vomiting starting ___ which correlated with transition from IV
unasyn to oral augmentin which he could not tolerate and abx
were later completed with IV (as above). His esophageal
discomfort is most likely acute irritation from emesis on top of
his chronic esophageal pain. Vomiting likely ___ altered
esophageal anatomy, with unclear sphincter control. Throughout,
exam was reassuring against new acute process. He was continued
on his home chronic pain regimen of oxycodone 30mg PO q6h:prn.
He was given Zofran for nausea and a malox and lidocaine oral
solution prn for visceral esophageal and abdominal discomfort.
Encouraged small bites alternating with small sips with the
majority of his nutritional needs with jtube feeding.
# Alcohol use disorder
Monitored on CIWA scale and received benzodiazepines
accordingly. Has a history of alcohol withdrawal seizure in
past. Ultimately stopped requiring benzodiazepines for
withdrawal on ___. Continued on Ativan 1mg PO BID, which he
takes at home, for anxiety.
# RUE DVT
Found on ___. Started treatment 10mg apixaban loading dose with
plan to transition to 5mg on ___.
# Transaminase elevation
AST 80 and ALT 48 on admission. Approximately 2:1 AST:ALT ratio,
likely ___ daily alcohol consumption. Also has a history of
positive hepatitis C antibody and viral load. Monitored
throughout admission and LFT abnormalities resolved on ___.
CHRONIC ISSUES
--------------
# Chronic pain
Continued on oxycodone 30mg Q6H
# HTN:
Continued on home amlodipine and lisinopril
# Asthma:
Continued on duoneb neb PRN
TRANSITIONAL ISSUES
-------------------
TRANSITIONAL ISSUES
[ ] Hepatology follow up scheduled for untreated Hep C. Also Hep
B non immune.
[ ] Colonic thickening on CT, correlate with colonoscopy
Note is again made of CTAP finding of ? thickening of the colon
at the hepatic flexure, possibly due to underdistension, but
recommendation for correlation with any recent colonoscopy, and
for consideration of colonoscopy. Colonoscopy done here in ___ was completely normal. Recommendation was for repeat in
___ years; this is reassuring against the likelihood of crc
evolving in the interim. Repeat colonoscopy at a sooner interval
can be considered on an outpatient basis in conjunction with
patients primary MD and or Gastroenterology
[ ] Consider changing pain regimen to more long acting opiates
such as oxycontin as the patient has admitted to prior providers
to taking more oxycodone than prescribed
[ ]Evaluate avascular necrosis of right femoral head as an
outpatient: Consider orthopedics referral. Noted on CT ___,
also noted on report from ___.
[ ]Consider enrollment in a substance abuse program as an
outpatient
[ ]Smoking cessation as an outpatient
[ ]Patient has an IVC filter that was placed in ___. Should
discuss with interventional radiology regarding removal of the
device.
[ ]Patient has a history of bilateral adrenal nodules that can
also be worked up as an outpatient
[ ]Started on apixaban for UE DVT. Given rx for 1 month. Please
continue to fill rx or refer to appropriate specialist PRN.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
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:
___ APPENDECTOMY LAPAROSCOPIC
History of Present Illness:
___ with history of PVD s/p bilateral iliac
stent on ASA who presents with RLQ abdominal pain. Patient noted
diffuse abdominal pain on ___ night. Since then, her pain has
localized to the right lower quadrant. Today she had nausea and
one episode of emesis. She denies fevers, chills, malaise,
diarrhea, and constipation. She has never had pain like this
before.
Past Medical History:
Hypertension, PVD, hypercholesterolemia
PSH: Peripheral vascular disease with bilateral iliac stents
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: 99.9 97 126/54 20 97%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, mildly distended, focal tenderness in RLQ with
voluntary guarding, +rovsing's sign
Ext: No ___ edema, ___ warm and well perfused
Medications on Admission:
Fluticasone 50 mcg BID, Lisinopril 20 mg daily, Simvastatin 40
mg daily, Aspirin 325 mg daily, Ceterizine 10 mg daily, Vitamin
D3 1000 U daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ceterizine 10 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right lower quadrant pain. Concern for appendicitis, less likely
ischemic bowel.
TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet
after the administration of intravenous contrast. Coronal and sagittal
reformations were acquired.
COMPARISON: None.
CT ABDOMEN: The lung bases are clear. The visualized portions of the heart
and pericardium are unremarkable.
Liver is unremarkable. The hepatic and portal veins are patent. The
gallbladder, pancreas, spleen, and adrenals are normal. The stomach and small
bowel are unremarkable. There is no portacaval, mesenteric, or
retroperitoneal lymphadenopathy. There is no free air or free fluid.
Aorto-bifem stent graft is noted.
CT PELVIS: The appendix is markedly dilated measuring 13 mm in greatest
dimension containing fecal material. An appendicolith is seen at the origin
(___:20). There is moderate surrounding fat stranding along with thickening
of the lateroconal fascia. There is diverticulosis of the descending colon
and sigmoid. The urinary bladder, uterus, adnexa, and rectum are normal.
Calcified uterine fibroid measuring approximately 14 mm is noted.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions suspicious for
malignancy.
IMPRESSION:
1. Acute appendicitis, uncomplicated. No drainable abscess. Surgical
consultation recommended.
2. Fibroid uterus.
3. Diverticulosis without evidence of diverticulitis.
These findings were identified at approximately 5:13 p.m. and relayed by Dr.
___ to Dr. ___ at 5:17 p.m. on ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ?APPENDICITIS
Diagnosed with ACUTE APPENDICITIS NOS
temperature: 99.9
heartrate: 97.0
resprate: 20.0
o2sat: 97.0
sbp: 126.0
dbp: 54.0
level of pain: 6
level of acuity: 3.0 | She was admitted to the Acute Care Surgery team and underwent CT
imaging of her abdomen/pelvis showing acute appendicitis,
uncomplicated with no drainable abscess. She was consented,
prepped and taken to the operating room for laparoscopic
appendectomy; perioperative antibiotics were given. There were
no intraoperative complications. Postoperatively her diet was
advanced and her home medications were resumed. Her pain was
well controlled with oral pain medications and she was
discharged on Tylenol and prn Oxycodone.
She was discharged to home with instructions for follow up with
her PCP and in the Acute Care Surgery clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
multiple falls
Major Surgical or Invasive Procedure:
bronchoscopy ___
History of Present Illness:
Patient is a ___ year old female with PMHx significant for
recent DVT treated here, afib, pacemaker for bradycardia, and
___
s/p evacuation in ___ at ___. She reports that since being in
rehab following ___ admission for DVT she noted gait disturbance
and has had multiple recent falls. She states that she has
recently been using a cane which is new for ___. She went to an
OSH for assessment and was found to have two possible brain
lesions on CT Head. She was transferred to ___ for further
management and care. She currently denies headache, nausea,
vomiting, dizziness, changes in vision, hearing, or speech,
changes in bowel or bladder function. She has difficulty
ambulating as above.
Past Medical History:
Past Medical History: She has a history of atrial fibrillation,
hypertension, hypercholesterolemia, hypothyroidism, bilateral
segmental pulmonary emboli in ___ to ___. ___ bilateral
DVTs. ?h/o OSA (wears CPAP, per family report)
Past Surgical History: She had placement of pacemaker for
bradycardia, bilateral cataract surgeries, a left
fronto-parietal craniotomy twice in ___ to ___ for subdural
hematoma, and IVC filter placement for bilateral pulmonary
emboli in the setting of subdural hematoma.
Social History:
___
Family History:
(Per Dr. ___ father died of an unspecified cancer
in ___. ___ mother died of dementia at age ___. ___ brother
might have died due to a blood clot after a cross-country flight
when he was in ___.
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nsytagmus
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, hospital, month/year
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: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally
Coordination: Dysmetria on left on finger-nose-finger, rapid
alternating movements, heel to shin. Normal on right
On Discharge:
VS: 98 100/52 87 18 98%RA
GEN: Alert, oriented to name, place and situation. no acute
signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 05:55PM BLOOD WBC-6.8 RBC-4.38 Hgb-12.9 Hct-41.7 MCV-95
MCH-29.5 MCHC-31.0 RDW-14.2 Plt ___
___ 09:30AM BLOOD WBC-6.5 RBC-4.04* Hgb-12.2 Hct-38.3
MCV-95 MCH-30.2 MCHC-31.9 RDW-14.8 Plt ___
___ 06:55AM BLOOD WBC-8.8 RBC-4.25 Hgb-12.6 Hct-40.3 MCV-95
MCH-29.7 MCHC-31.3 RDW-14.4 Plt ___
___ 06:55AM BLOOD ___ PTT-26.6 ___
___ 05:55PM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-143
K-4.0 Cl-106 HCO3-25 AnGap-16
___ 06:25AM BLOOD Glucose-102* UreaN-25* Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
___ 06:40AM BLOOD Glucose-109* UreaN-28* Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
___ 06:55AM BLOOD Glucose-110* UreaN-31* Creat-0.9 Na-136
K-4.4 Cl-102 HCO3-24 AnGap-14
___ 06:55AM BLOOD ALT-9 AST-12 TotBili-0.4
___ 08:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
___ 09:30AM BLOOD Calcium-9.5 Mg-2.2
___ 06:55AM BLOOD Calcium-9.0 Phos-5.8*# Mg-2.1
___ 03:10AM BLOOD Digoxin-1.1
==================================
Radiology
==================================
CT HEAD W/ & W/O CONTRASTStudy Date of ___ 11:42 AM
FINDINGS: Three abnormally-enhancing lesions are seen in the
brain with
significant amount of surrounding edema, out of proportion to
the size of the
lesion, typical of metastases.
These include:
1. 1.9 x 1.9 cm lesion in the right parietal lobe (2D:20) with
rim-enhancement and a hypoenhancing center, representing cystic
necrosis.
2. 2.0 x 1.6 cm lesion in the left cerebellar hemisphere
(2D:10) with
rim-enhancement and a hypoenhancing center, also suggesting
necrosis.
3. 0.9 x 0.8 cm intrinsically T1-hyperintense lesion which
limits assessment
of enhancement in the parafalcine region of the right occipital
lobe (2D:18)
consistent with a small hemorrhagic metastasis.
There is mild mass effect from the extensive edema resulting in
leftward
deviation of midline structures which measures 6 mm at the level
of the
foramen of ___. There is also effacement of the basal
cisterns. The
cerebellar tonsils are above the level of the foramen magnum. No
leptomeningeal involvement is identified.
Post-craniotomy changes are seen in the left frontoparietal
region from remote
evacuation of a subdural hemorrhage. There is no evidence of
fracture or bone
destructive lesion. The paranasal sinuses, mastoid air cells
and middle ear
cavities are clear. Although this study is not tailored for
assessment of
vasculature, there is no evidence of aneurysm in the circle of
___ or main
vessels of anterior and posterior circulation. The carotid and
vertebrobasilar system are patent. The major dural venous
sinuses opacify
normally. Incidentally noted calcification of the basal ganglia
is present.
IMPRESSION:
1. Three metastatic lesions, as described above, one of which
appears
hemorrhagic and the other two show peripheral enhancement, with
edema out of
proportion to the size of the lesions typical of metastases.
Constellation of these findings, including a large peripheral
spiculated mass
with "pleural tails" in the left lung, on the recent chest CT,
is suggestive
of metastatic bronchogenic carcinoma, likely adenocarcinoma.
2. Mass effect from extensive edema is seen in the form of mild
effacement of
the basal cisterns and leftward subfalcine herniation.
CHEST (PA & LAT)Study Date of ___ 4:47 ___
FINDINGS: AP upright and lateral views of the chest provided
demonstrate
dual-lead pacemaker with left chest wall pacer pack and leads
extending to the
region of the right atrium and right ventricle. As seen on
prior exams is a
right upper lobe mass measuring approximately 5-cm in maximal
diameter.
Margins appear irregular and findings are compatible with
malignancy. The
heart and mediastinal contour appear stable. No acute bony
injury. IVC
filter partially imaged in the right mid abdomen.
IMPRESSION: No acute traumatic findings. LUL mass.
CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSStudy Date of
___ 11:42 AM
FINDINGS:
CT ABDOMEN:
There is a perfusion anomaly noted within segment IV of the
liver. There are
no focal liver lesions. The spleen appears unremarkable. There
are right
renal hypodensities which are too small to characterize. There
are right
renal parapelvic cysts. There is a 3mm hypodense lesion in the
tail of the
pancreas (3:62), which most likely represents a small
intraductal papillary
mucinous neoplasm. The adrenal glands appear unremarkable.
There is a large
gallstone within a nondistended gallbladder. There is no
intra-abdominal or
pelvic lymphadenopathy.
There is moderate-to-severe atherosclerosis of the abdominal
aorta and major
branch vessels. There is an inferior vena cava filter noted in
satisfactory
position. Below the level of the IVC filter, there is thrombus
noted within
the inferior vena cava and bilateral iliac veins and the left
common femoral
vein.
CT Pelvis:
The uterus is absent. The bladder appears unremarkable.
OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic bone lesions appreciated.
Mild-to-moderate
degenerative changes of the lumbar spine.
IMPRESSION:
1. No evidence of intra-abdominal metastases.
2. Cholelithiasis.
3. Right renal parapelvic cysts and renal hypodensities too
small to
characterize.
4. IVC filter with large clot burden more distal to the IVC
filter and common
iliac veins and left femoral vein.
CT CHEST W/CONTRASTStudy Date of ___ 11:56 AM
FINDINGS:
43 x 40 x 37 mm (AP x transverse x CC ___ left upper
lobe
juxtamediastinal mass is spiculated and may contain a few small
areas of
cavitation superiorly. This lesion is inseparable from and may
invade the
left upper mediastinum. A few small satellite nodules measure 8
x 4 mm (5:74)
and 6 x 4 mm (5:66). 2 mm right upper lobe ground-glass nodule
(5:91) is
unchanged since ___. Minimal emphysema is upper zone
predominant.
Bibasilar atelectasis is mild. No pleural effusion or
pneumothorax. The
central airways are patent.
Enlarged mediastinal lymph nodes range in diameter up to 9 mm
right upper
paratracheal, 12 mm left lower paratracheal, and 24 x 10 mm
subcarinal.
Axillary and supraclavicular lymph nodes are not pathologically
enlarged.
The great vessels are normal caliber. Small mural
calcifications are
scattered along the thoracic aorta. The heart size is mildly
enlarged and
leads of a left chest wall pacer terminates in the right atrium
and right
ventricle. No pericardial effusion. The thyroid is normal.
The esophagus is unremarkable. For the intra-abdominal
findings, please refer
to the separately issued CT abdomen report.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for
malignancy. Multilevel thoracic spine degenerative changes are
similar to
prior.
IMPRESSION:
4.3 x 4.0 x 3.7 cm left upper lobe spiculated mass consistent
with lung
malignancy may invade the left upper mediastinum. Multiple
enlarged
metastatic mediastinal lymph nodes.
Findings were communicated via phone call by Dr. ___ to
Dr. ___ on ___ at 1756 ___.
The study and the report were reviewed by the staff radiologist.
Echocardiogram
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). False LV tendon (normal variant). Doppler parameters are
indeterminate for LV diastolic function. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. Moderate
(2+) MR.
___ VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. Mild PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is 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) 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. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal biventricular cavity size and global/regional systolic
function. Diastolic parameters indeterminate to asses diastolic
function. Moderate mitral regurgitation. Borderline pulmonary
artery systolic hypertension.
Compared with the prior report (images unable to be reviewed) of
___, the severity of mitral regurgitation has increased.
==================================
Pathology
==================================
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: FINE NEEDLE ASPIRATION, 4 L EBUS TBNA
DIAGNOSIS:
EBUS, TBNA 4L:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic adenocarcinoma.
SPECIMEN DESCRIPTION:
Received: specimen in Cytolyt.
Prepared: 1 monolayer
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE, LEFT
DIAGNOSIS:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma.
SPECIMEN DESCRIPTION:
Received: 30 ml, bloody mucoid fluid.
Prepared: 1 monolayer
==================================
Procedures
==================================
bronchoscopy ___
Procedure: The procedure, indications, preparation and
potential complications were explained to the patient, who
indicated his understanding and signed the corresponding consent
forms. A standard time out was performed as per protocol. The
procedure was performed for diagnostic purposes at the operating
room. A physical exam was performed. The bronchoscope was
introduced orally and advanced under direct visualization until
the tracheobronchial tree was reached.The procedure was not
difficult. The quality of the preparation was good. The patient
tolerated the procedure well. There were no complications.
other findings:pt brought to OR where GETA was induced and LMA
placed. Flexible bronchoscope was inserted through LMA and
airway examined, Extrinsic compression of LUL apicoposterior
segment was seen. Transbronchial brush and BAl were performed in
that segment following confirmation of . Next scope was removed
and flexible bronchoscope with EBUS was inserted and advanced to
station 4L where multiple TBNA were performed. Scope removed.
Impression: Pt brought to OR where GETA was induced and LMA
placed. Flexible bronchoscope was inserted through LMA and
airway examined, Extrinsic compression of LUL apicoposterior
segment was seen. Transbronchial brush and BAl were performed in
that segment followi
Otherwise normal to tracheobronchial tree
Recommendations: Followup biopsy
Additional notes: flexible bronchoscopy with EBUS TBNA of
station 4L flexible bronchoscopy with BAL flexible bronchoscopy
with brush
Medications on Admission:
vitamin B12, Citracal, vitamin D, MVI, tylenol, coalce, iron,
metoprolol, digoxin, levothyroxine, lovenox, mirtazpipine,
pravastatin, rivastigmine
Discharge Medications:
1. Digoxin 0.25 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO ___
3. Metoprolol Tartrate 25 mg PO TID
4. Pravastatin 40 mg PO DAILY
5. Dexamethasone 4 mg PO Q12H
6. Cyanocobalamin 1000 mcg PO DAILY
7. Citracal Regular (calcium citrate-vitamin D3) 2 TAB ORAL
DAILY
8. Famotidine 20 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. LeVETiracetam 500 mg PO BID
11. Mirtazapine 15 mg PO HS
12. TraZODone 25 mg PO HS:PRN insomnia
13. rivastigmine 1.5 mg ORAL Q8AM AND Q8PM
14. Multivitamins 1 TAB PO DAILY
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lung adenocarcinoma with symptomatic brain metastases
rapid atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior exam dated earlier today.
CLINICAL HISTORY: Brain mass, status post fall, assess for traumatic injury
in the chest.
FINDINGS: AP upright and lateral views of the chest provided demonstrate
dual-lead pacemaker with left chest wall pacer pack and leads extending to the
region of the right atrium and right ventricle. As seen on prior exams is a
right upper lobe mass measuring approximately 5-cm in maximal diameter.
Margins appear irregular and findings are compatible with malignancy. The
heart and mediastinal contour appear stable. No acute bony injury. IVC
filter partially imaged in the right mid abdomen.
IMPRESSION: No acute traumatic findings. LUL mass.
Radiology Report
EXAM: Left elbow, three views.
CLINICAL INFORMATION: Left elbow laceration status post fall.
COMPARISON: None.
FINDINGS: Three views of the left elbow were obtained. No evidence of acute
fracture or dislocation is seen. No posterior joint effusion is seen.
Possible skin disruption is seen at the posterior elbow, if this is site of
laceration. No concerning osteoblastic or lytic lesions are seen.
IMPRESSION: No acute fracture or dislocation.
Radiology Report
HISTORY: Multiple intracranial metastases and left upper lung lesion.
Evaluate for malignancy.
TECHNIQUE: Axial helical MDCT of the abdomen and pelvis was performed prior
to and after the administration of 130 mL of Omnipaque intravenous contrast in
multiple phases. Oral contrast was also given to the patient prior to the
procedure. A CT chest and head were also performed and will be dictated
separately. Multiplanar sagittal and coronal reformatted images were
generated. DLP: 1217.04 mGy-cm.
COMPARISON: No prior CT abdomen is available for comparison. Compared to
prior CT chest from ___.
FINDINGS:
CT ABDOMEN:
There is a perfusion anomaly noted within segment IV of the liver. There are
no focal liver lesions. The spleen appears unremarkable. There are right
renal hypodensities which are too small to characterize. There are right
renal parapelvic cysts. There is a 3mm hypodense lesion in the tail of the
pancreas (3:62), which most likely represents a small intraductal papillary
mucinous neoplasm. The adrenal glands appear unremarkable. There is a large
gallstone within a nondistended gallbladder. There is no intra-abdominal or
pelvic lymphadenopathy.
There is moderate-to-severe atherosclerosis of the abdominal aorta and major
branch vessels. There is an inferior vena cava filter noted in satisfactory
position. Below the level of the IVC filter, there is thrombus noted within
the inferior vena cava and bilateral iliac veins and the left common femoral
vein.
CT Pelvis:
The uterus is absent. The bladder appears unremarkable.
OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic bone lesions appreciated. Mild-to-moderate
degenerative changes of the lumbar spine.
IMPRESSION:
1. No evidence of intra-abdominal metastases.
2. Cholelithiasis.
3. Right renal parapelvic cysts and renal hypodensities too small to
characterize.
4. IVC filter with large clot burden more distal to the IVC filter and common
iliac veins and left femoral vein.
Radiology Report
INDICATION: ___ female with probable multiple intracranial metastases
and left upper lobe lung lesion seen on chest x-ray; evaluate.
COMPARISON: Head CT from outside institution from ___ as well as
multiple prior head CTs from our institution, of which the most recent was
from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head before
and after the administration of IV contrast. Coronal, sagittal, and thin
slice bone reformats were generated.
DLP: 892 mGy-cm.
CTDI: 54.09 mGy.
FINDINGS: Three abnormally-enhancing lesions are seen in the brain with
significant amount of surrounding edema, out of proportion to the size of the
lesion, typical of metastases.
These include:
1. 1.9 x 1.9 cm lesion in the right parietal lobe (2D:20) with
rim-enhancement and a hypoenhancing center, representing cystic necrosis.
2. 2.0 x 1.6 cm lesion in the left cerebellar hemisphere (2D:10) with
rim-enhancement and a hypoenhancing center, also suggesting necrosis.
3. 0.9 x 0.8 cm intrinsically T1-hyperintense lesion which limits assessment
of enhancement in the parafalcine region of the right occipital lobe (2D:18)
consistent with a small hemorrhagic metastasis.
There is mild mass effect from the extensive edema resulting in leftward
deviation of midline structures which measures 6 mm at the level of the
foramen of ___. There is also effacement of the basal cisterns. The
cerebellar tonsils are above the level of the foramen magnum. No
leptomeningeal involvement is identified.
Post-craniotomy changes are seen in the left frontoparietal region from remote
evacuation of a subdural hemorrhage. There is no evidence of fracture or bone
destructive lesion. The paranasal sinuses, mastoid air cells and middle ear
cavities are clear. Although this study is not tailored for assessment of
vasculature, there is no evidence of aneurysm in the circle of ___ or main
vessels of anterior and posterior circulation. The carotid and
vertebrobasilar system are patent. The major dural venous sinuses opacify
normally. Incidentally noted calcification of the basal ganglia is present.
IMPRESSION:
1. Three metastatic lesions, as described above, one of which appears
hemorrhagic and the other two show peripheral enhancement, with edema out of
proportion to the size of the lesions typical of metastases.
Constellation of these findings, including a large peripheral spiculated mass
with "pleural tails" in the left lung, on the recent chest CT, is suggestive
of metastatic bronchogenic carcinoma, likely adenocarcinoma.
2. Mass effect from extensive edema is seen in the form of mild effacement of
the basal cisterns and leftward subfalcine herniation.
Radiology Report
HISTORY: Multiple brain metastases and left upper lobe lesion on chest
radiograph.
COMPARISON: Multiple prior chest radiographs, most recently ___. ___ chest CTA.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the upper
abdomen. IV Omnipaque contrast was administered. Axial images were
interpreted in conjunction with sagittal and coronal reformats.
FINDINGS:
43 x 40 x 37 mm (AP x transverse x CC ___ left upper lobe
juxtamediastinal mass is spiculated and may contain a few small areas of
cavitation superiorly. This lesion is inseparable from and may invade the
left upper mediastinum. A few small satellite nodules measure 8 x 4 mm (5:74)
and 6 x 4 mm (5:66). 2 mm right upper lobe ground-glass nodule (5:91) is
unchanged since ___. Minimal emphysema is upper zone predominant.
Bibasilar atelectasis is mild. No pleural effusion or pneumothorax. The
central airways are patent.
Enlarged mediastinal lymph nodes range in diameter up to 9 mm right upper
paratracheal, 12 mm left lower paratracheal, and 24 x 10 mm subcarinal.
Axillary and supraclavicular lymph nodes are not pathologically enlarged.
The great vessels are normal caliber. Small mural calcifications are
scattered along the thoracic aorta. The heart size is mildly enlarged and
leads of a left chest wall pacer terminates in the right atrium and right
ventricle. No pericardial effusion. The thyroid is normal.
The esophagus is unremarkable. For the intra-abdominal findings, please refer
to the separately issued CT abdomen report.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Multilevel thoracic spine degenerative changes are similar to
prior.
IMPRESSION:
4.3 x 4.0 x 3.7 cm left upper lobe spiculated mass consistent with lung
malignancy may invade the left upper mediastinum. Multiple enlarged
metastatic mediastinal lymph nodes.
Findings were communicated via phone call by Dr. ___ to Dr. ___
___ on ___ at 1756 ___.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with known lung mass after
biopsy.
AP radiograph of the chest was reviewed.
Left upper lobe opacity is due to the known mass. There is no evidence of
pneumothorax. Heart size and mediastinum are stable. Pacemaker leads
terminate in expected locations of right atrium and right ventricle. No
interval development of pleural effusion was noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, NEW MASS
Diagnosed with BRAIN CONDITION NOS, CHEST SWELLING/MASS/LUMP
temperature: 98.4
heartrate: 60.0
resprate: 20.0
o2sat: 99.0
sbp: 156.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ y/o F with frequent falls presents with cerebellar and R
frontal hypodensities question for lesions. She was admitted to
neurosurgery for further evaluation. On exam, she was alert and
oriented to self, month and year and place and MAE with good
strength. She was found to have L dysmetria and gait
instability. On ___, she was stable on exam. CT head w/ and w/o
contrast and CT torso were ordered to further evaluate.
neurooncology was consulted for possible transfer to their
service for further evaluation and treatment. she was continued
on IV Dex 4 Q6 which at discharge was changed to 4mg PO BID at
discharge.
# metastatic lung CA: Brain metastases with spiculated mass in
left upper lung. She had EBUS on ___ which showed metastatic
adenocarcinoma. At this time no further stains or mutation
studies are available. She will f/u with medical oncology as an
outpatient. She is not interested in chemotherapy, but may opt
for a targeted therapy if one is available for ___. She was seen
by radiation oncology while inpatient. She was initially
reluctant to have whole brain radiation, but as there would only
be 5 planned fractions she is now considering it. She is to meet
with Dr. ___ next week to discuss starting
treatment. She is going to a rehab at discharge and ___ family
will transport ___. For ___ brain lesions she continues on
Keppra and dexamethasone. She had an EEG as reported above.
Chronic/Resolved Issues
# agitation: likely multifactorial with newly found brain mets
as well as delirium. she required haldol and ativan earlier in
___ stay but the last few days of stay no problems. EEG ___
showed slow background, consistent with a moderate
encephalopathy (nonspecific). There were no electrographic
seizures.
# h/o afib and bradycardia s/p PPM. during this admission she
had episodes of paroxysmal rapid afib with rates up to 140s. ___
metoprolol was increased to 25mg TID with improvement in rate.
echo shows slightly worse mitral regurg. Continue digoxin,
beta-blocker.
# h/o PE and recent DVTs: prior to admission she was on
enoxaparin therapeutic dosing but given untreated brain
metastases she was taken off of full anticoagulation. She was
kept on prophylactic dose heparin. Once ___ brain metastases are
treated with radiation she can resume lovenox. She has an IVC
filter.
# h/o OSA: wears CPAP at night, which was continued here
# h/o HL: cont pravastatin
# hypothyroidism: cont levothyroxine
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
choledocholithiasis
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ was in her usual state of health when she suddenly
experienced intense pain in her chest and right upper abdomen.
She states that she had never had similar pain before and the
pain was very intense so she immediately headed to an OSH. At
OSH, she had a negative cardiac workup and a RUQUS with CBD 1 cm
and concern for choledocolithiasis and cholecystitis. She
reports no known history of gallstones. She
preferred to be treated at ___ if she was having surgery so
left the OSH to come here.
She reports that she vomited once on the way back from the other
hospital and one time when she returned home and tried to drink
some juice. She has been having some intermittent nausea since
the pain started. After receiving pain medications at OSH, she
states that she has not been in pain. She has not had a bowel
movement since yesterday afternoon, prior to when the pain
started. She has been unable to eat due to pain and nausea since
yesterday afternoon.
Past Medical History:
HTN
Physical Exam:
itals: 24 HR Data (last updated ___
Temp: 98.1 (Tm 98.6), BP: 119/62 (117-136/62-74), HR: 90
(75-90), RR: 18 (___), O2 sat: 93% (93-96), O2 delivery: Ra
Fluid Balance (last updated ___ @ ___
Last 8 hours Total cumulative 140ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 220ml, Urine Amt 220ml
Last 24 hours Total cumulative 140ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 220ml, Urine Amt 220ml
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs. Laparoscopy
incisions without signs of infection.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amlodipine-benazepril 2.5-10 mg oral DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth four times a day Disp
#*8 Capsule Refills:*0
2. amlodipine-benazepril 2.5-10 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with epigastric pain// eval PNA; eval cholecystitis
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.A subtle retrocardiac opacity could
reflect an early pneumonia in the left lower lobe in the correct clinical
context. Otherwise, the lungs are clear. No large effusion or pneumothorax.
Cardiomediastinal silhouette is normal. Bony structures are intact. No free
air below the right hemidiaphragm.
IMPRESSION:
Subtle left lower lobe opacity could represent pneumonia in the correct
clinical context. Please correlate clinically.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with epigastric pain// eval PNA; eval cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 10 mm
GALLBLADDER: There are stones in the gallbladder, which appears mildly
distended, without wall edema.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 11.1 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Cholelithiasis without convincing evidence of cholecystitis. Dilated CBD may
be due to a distal duct stone. Please correlate clinically.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Epigastric pain
Diagnosed with Calculus of bile duct w/o cholangitis or cholecyst w/o obst, Right upper quadrant pain
temperature: 98.4
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 145.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | Ms ___ was admitted on ___ for management of
choledocholithiasis and possible cholecystitis. She was taken to
the operating room and underwent a laparoscopic cholecystectomy.
Please see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She was subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per ED note, Mr. ___ is a ___ year old man with DM2, HTN, OSA
on CPAP, recurrent atrial fibrillation on apixaban who presented
to the ED with a week long history of productive cough and night
sweats. His symptoms began slowly and felt like a cold that did
not resolve. He recently traveled for a ___ ___ and
stayed in a hotel, however his symptoms started just prior to
this. He admits to dyspnea on exertion, decreased appetite, and
loose stools however denies dark stools or blood in the stools.
He denies neck pain/stiffness, headache, abdominal pain, and
dysuria.
In the ED, initial vital signs were notable for T 98.5, BP
133/85, RR 18, and SpO2 of 90% on RA. He was briefly febrile on
100.5, and developed a new O2 requirement of 3L during his ED
course.
Labs were significant for BUN of 26 and anion gap of 19. Sodium
was within normal limits. proBNP was mildly elevated to 875. CBC
had elevated WBC to 16.8 with neutrophilic predominance. A CXR
was conducted and was remarkable for consolidation of the
posterior segment of the right lower lobe. A diagnosis of
community acquired pneumonia was made and the patient was given
azithromycin and ceftriaxone. He remained HDS on 3L O2.
The patient remained HDS during his uneventful transfer to the
floor. VS on arrival were stable, and he was weaned off NC to
room air. He reports feeling much improved since his arrival to
the ED but he feels very cold.
Past Medical History:
-DM
-AF, on pradaxa
-HTN
-HLD
-OSA on home CPAP
-S/p hernia repair
-S/p septoplasty
OTHER PAST MEDICAL HISTORY:
- cholesterol emboli in L eye
- obstructive sleep apnea - currently not on CPAP
Social History:
___
Family History:
Father has history of MI in his ___, DM
Mother had COPD and stroke
sister has diabetes, unsure if type 1 or 2
Maternal grandmother with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1622)
Temp: 98.2 (Tm 98.2), BP: 119/73, HR: 83, RR: 18, O2 sat:
93%, O2 delivery: ra
GENERAL: Alert and interactive. appears tremulous
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Decreased breath sounds at bases, fine crackles over
right. Otherwise clear to auscultation
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 2305)
Temp: 97.6 (Tm 98.4), BP: 130/53 (116-130/53-67), HR: 61
(61-75), RR: 18, O2 sat: 93% (91-95), O2 delivery: Ra
GENERAL: Alert and interactive. appears tremulous
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Decreased breath sounds at bases, fine crackles over
right. Otherwise clear to auscultation
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: R sided inguinal hernia that is soft, non tender and
without erythema or redness. Normal bowels sounds, non
distended,
non-tender to deep palpation in all four quadrants. No
organomegally
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Pertinent Results:
ADMISSION LABS.
___ 09:44AM BLOOD WBC-16.8* RBC-4.32* Hgb-13.1* Hct-39.6*
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.5 RDWSD-45.9 Plt ___
___ 09:44AM BLOOD Glucose-70 UreaN-26* Creat-1.1 Na-142
K-4.1 Cl-100 HCO3-23 AnGap-19*
___ 09:44AM BLOOD ALT-28 AST-57* AlkPhos-89 TotBili-0.6
___ 07:25AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.4*
DISCHARGE LABS.
___ 06:40AM BLOOD WBC-8.9 RBC-3.42* Hgb-10.4* Hct-31.5*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.0 RDWSD-47.8* Plt ___
___ 03:05PM BLOOD Glucose-269* UreaN-21* Creat-0.7 Na-143
K-3.8 Cl-104 HCO3-38* AnGap-1*
___ 03:05PM BLOOD Calcium-8.1* Phos-1.9* Mg-1.5*
___ 07:25AM BLOOD ALT-20 AST-33 LD(LDH)-241 CK(CPK)-61
AlkPhos-66 TotBili-0.6
Legionella Urinary Antigen (Final ___:
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
MRSA SWAB NEGATIVE
CXR
Right lower lobe pneumonia. Follow up radiographs after
treatment are
recommended to ensure resolution of this finding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Metoprolol Succinate XL 100 mg PO DAILY
4. 70/30 12 Units Breakfast
70/30 3 Units Bedtime
5. Atorvastatin 40 mg PO QPM
6. Lisinopril 10 mg PO DAILY
7. dulaglutide 0.75 mg/0.5 mL subcutaneous Other
Discharge Medications:
1. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. 70/30 12 Units Breakfast
70/30 3 Units Bedtime
3. Apixaban 5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. dulaglutide 0.75 mg/0.5 mL subcutaneous Other
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Legionaire disease
SECONDARY DIAGNOSES
===================
Inguinal hernia
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 productive cough// eval PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are unremarkable
with mild atherosclerotic calcifications of the aortic knob. The pulmonary
vasculature is normal. New focal consolidation is seen in the right lower
lobe concerning for pneumonia. Left lung is grossly clear. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
Right lower lobe pneumonia. Follow up radiographs after treatment are
recommended to ensure resolution of this finding.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fatigue, ILI
Diagnosed with Pneumonia, unspecified organism
temperature: 98.5
heartrate: 116.0
resprate: 18.0
o2sat: 90.0
sbp: 133.0
dbp: 85.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
===============
Mr. ___ is a ___ year old man with a history of atrial
fibrillation s/p PVI still on apixaban who presented with a week
long history of influenza-like-illness, found to have pneumonia
on chest x-ray along with new O2 requirement admitted to
medicine for IV antibiotics. Urine legionella antigen was
positive. Condition improved, discharged on PO azithromycin.
TRANSITIONAL ISSUES
===================
[ ] Patient R inguinal hernia this admission, consider surgical
evaluation if patient desires
[ ] Being discharged on 7 day course of azithromycin (D1: ___
D7: ___
[ ] Patient with hypokalemia, hypomagnesemia, hypophosphatemia
this admission. Should follow up electrolytes at next
appointment
ACUTE ISSUES
============
#Legionella Pneumonia
Given influenza like symptoms for 1 week and consolidation of
chest x-ray a diagnosis of pneumonia was made. Given his new O2
requirement in the ED with CURB-65 score of 2 and PSI of 72 he
was admitted to medicine for further management. He was given
acetaminophen for pain and fever control, along with IV
ceftriaxone and azithromycin for empiric CAP coverage. This
resulted in dramatic improvement of his symptoms. Urine
legionella antigen was found to be positive. He was discharged
on a 4 day course of azithromycin 500mg qd
#Hypokalemia
Potassium was found to be 2.9 on ___. Most likely in the
setting of acute illness and poor oral intake with possible GI
losses. Repleted prior to discharge.
#Hypomagnesemia
Magnesium was found to be low on this admission, possibly in the
setting of poor PO intake. Repleted prior to discharge.
#Hypophosphatemia.
Phosphate found to be low on this admission, possibly in the
setting of poor PO intake. Repleted prior to discharge.
CHRONIC ISSUES
==============
#Atrial fibrillation s/p PVI
Patient with a diagnosis of atrial fibrillation. Had Pulmonary
vein isolation on ___, and EKG on admission was normal sinus
rhythm. Apixiban and metoprolol were continued during his
hospitalization.
#Diabetes mellitus
Patient on home insulin regimen. Home insulin regimen was
reduced in the setting of poor PO intake. Atorvostatin was
continued as well.
#Hypertension
Home lisinopril was continued during his admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
methotrexate / pantoprazole / niacin / doxazosin / lidocaine
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Bronchoscopy ___
Renal biopsy ___
History of Present Illness:
Mr ___ is a ___ man with a history of hypertension,
hyperlipidemia, and rheumatoid arthritis, who presents with lung
lesions and acute kidney injury.
2 weeks ago, he developed a persistent cough and worsening
shortness of breath. He had no fevers, nasal congestions, or
other signs of infection, and no sick contacts. His cough and
dyspnea got severe, so he presented to his PCP, who ordered a
CXR. CXR showed a consolidation, but PCP was concerned about
degree of dyspnea, so he ordered a CTA chest. This showed no PE,
but was concerning for infiltrative process. At this point, his
dyspnea continued to worsen, and PCP checked labs, which were
notable for new Cr 3.4, up from baseline of normal. During this
time, the patient had no chest pain, flank pain, dysuria,
hematuria, or frothy urine. He has had 3 episodes of vomiting,
but no diarrhea.
His PCP instructed him to come to the ED, and was referred to
___ for urgent Nephrology consultation.
- In the ED, initial vitals were: 98.1 72 200/55 18 97% RA
- Exam notable for: no CVAT, 1+ pitting edema to knees
bilaterally
- Labs notable for: Cr 3.1
- Imaging was notable for: renal U/S with no hydro
- Patient was given:
___ 05:35 IVF NS ___ Started
___ 09:29 SC Insulin 2 Units ___
- Vitals on transfer: 97.9 64 171/97 16 96% RA
Upon arrival to the floor, patient reports feeling well. He does
not have headache, and is breathing comfortably at rest. He is
still coughing a dry cough. He notes that his legs have gotten
more swollen today. Otherwise, no complaints.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- Rheumatoid arthritis
- HTN
- HLD
- TIA (on Plavix)
- Myocardial infarction ___ viral process, but clean coronaries
- T2DM on insulin
Social History:
___
Family History:
No family history of kidney disease. 1 sister with
hypothyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITAL SIGNS: 97.0 AdultAxillary 201 / 86 L Lying 67 20 96 Ra
GENERAL: Sitting comfortably in bed, NAD
HEENT: no scleral icterus, mmm
NECK: no JVD, supple
CARDIAC: rrr, ___ systolic murmur at ___
LUNGS: clear bilaterally with faint expiratory wheezing at
bases
ABDOMEN: soft, NT/ND, +bs, no suprapubic pain
EXTREMITIES: warm, 1+ pitting edema to shins bilaterally
NEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/
purpose
SKIN: no rashes or jaundice
BACK; no CVA tenderness
DISCHARGE PHYSICAL EXAM:
===========================
VITAL SIGNS: 98.5 PO 161 / 54L Lying 57 18 97 Ra
GENERAL: Sitting comfortably in chair, NAD
HEENT: no scleral icterus, mmm
NECK: supple
CARDIAC: rrr, ___ systolic murmur at ___
LUNGS: CTAB
ABDOMEN: soft, NT/ND, +bs
EXTREMITIES: warm, trace pitting edema to shins bilaterally
NEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/
purpose
SKIN: There are scattered erythematous, non-blanching, ~purpuric
lesions on the bilateral UEs on forearms and left side of back
Pertinent Results:
ADMISSION LABS:
===========================
___ 10:50PM BLOOD WBC-4.9 RBC-2.65* Hgb-8.3* Hct-24.6*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.0 RDWSD-44.1 Plt ___
___ 10:50PM BLOOD Neuts-78.2* Lymphs-8.2* Monos-10.6
Eos-2.2 Baso-0.4 Im ___ AbsNeut-3.83 AbsLymp-0.40*
AbsMono-0.52 AbsEos-0.11 AbsBaso-0.02
___ 10:50PM BLOOD ___ PTT-34.9 ___
___ 10:50PM BLOOD Glucose-228* UreaN-54* Creat-3.1*# Na-138
K-4.3 Cl-97 HCO3-25 AnGap-16
___ 10:50PM BLOOD Calcium-9.6 Phos-5.1* Mg-2.4
___ 10:50PM BLOOD CRP-59.0*
IMAGING/STUDIES:
===========================
___ RENAL U/S:
1. No hydronephrosis. Both ureteral jets are visualized.
2. Nonobstructive nephrolithiasis of the left kidney.
___ronchus centric opacities in the right upper lobe and both
lower lobes
concerning for multifocal pneumonia.
Small bilateral effusions and mild interstitial edema.
Small mediastinal lymph nodes could be reactive.
DISCHARGE LABS:
===========================
___ 07:40AM BLOOD WBC-6.6 RBC-2.46* Hgb-7.7* Hct-23.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.2 RDWSD-45.1 Plt ___
___ 07:40AM BLOOD ___ PTT-33.1 ___
___ 07:40AM BLOOD Glucose-120* UreaN-41* Creat-1.8* Na-145
K-4.3 Cl-110* HCO3-23 AnGap-12
___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
OTHER PERTINENT LABS
===========================
___ 06:38AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-1+* Tear Dr-OCCASIONAL
___ 06:38AM BLOOD Ret Aut-2.2* Abs Ret-0.05
___ 06:38AM BLOOD ALT-19 AST-20 LD(LDH)-166 AlkPhos-35*
TotBili-<0.2
___ 01:20PM BLOOD CK(CPK)-414*
___ 10:48PM BLOOD CK(CPK)-464*
___ 06:30AM BLOOD CK-MB-5 cTropnT-0.05*
___ 01:20PM BLOOD CK-MB-7 cTropnT-0.07*
___ 10:48PM BLOOD CK-MB-7 cTropnT-0.04*
___ 05:28AM BLOOD CK-MB-6 cTropnT-0.06*
___ 06:38AM BLOOD calTIBC-268 Ferritn-68 TRF-206
___ 06:20AM BLOOD TSH-5.7*
___ 06:20AM BLOOD Free T4-0.9*
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:00PM BLOOD ANCA-NEGATIVE B
___ 10:50PM BLOOD CRP-59.0*
___ 05:00PM BLOOD ___
___ 06:38AM BLOOD CRP-16.7*
___ 05:30PM BLOOD PEP-NO SPECIFI
___ 05:00PM BLOOD C3-164 C4-28
___ 06:30AM BLOOD HIV Ab-NEG
___ 05:00PM BLOOD HCV Ab-NEG
___ 09:35AM BLOOD SM ANTIBODY-Test
___ 09:35AM BLOOD RO & ___
___ 09:35AM BLOOD RNP ANTIBODY-Test
___ 09:35AM BLOOD ALDOLASE-Test
___ 06:38AM BLOOD SED RATE-Test
___ 05:00PM BLOOD ANTI-GBM-Test
___ 06:12AM BLOOD SED RATE-Test Name
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 100 mg PO BID
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Gemfibrozil 600 mg PO BID
4. Furosemide 40 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Lisinopril 40 mg PO DAILY
8. Glargine 30 Units Bedtime
9. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. HydrALAZINE 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
2. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Glargine 30 Units Bedtime
6. Spironolactone 100 mg PO BID
7. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until at least one week after kidney
biopsy. Do not resume until after discussing with kidney doctor
8. HELD- Gemfibrozil 600 mg PO BID This medication was held. Do
not restart Gemfibrozil until instructed to resume by your
doctor. This medication may have caused muscle inflammation
9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed to resume by your
doctor. This medication cannot be restarted right away because
it can cause kidney injury
10. HELD- Rosuvastatin Calcium 40 mg PO QPM This medication was
held. Do not restart Rosuvastatin Calcium until instructed to
resume by your doctor. This medication may have caused muscle
inflammation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute kidney injury
- bilateral pulmonary infiltrates
SECONDARY DIAGNOSES
- Hypertensive urgency
- Dyspnea on exertion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED RENAL BIOPSY BY NEPHROLOGIST
INDICATION: ___ year old man history of DM presented with worsening renal
function(from 1.2-2.2 in 3 months with 10g proteinuria// etiology for
worsening renal function
TECHNIQUE: Real-time grayscale ultrasound imaging for biopsy guidance.
COMPARISON: Renal ultrasound ___
OPERATORS: Dr. ___ Dr. ___ sonographic guidance for biopsy
that was performed by the Nephrology team.
FINDINGS:
This procedure was performed by the Nephrology team; please see Nephrology
procedure note for further details.
Real-time ultrasound guidance for percutaneous renal biopsy was provided by
radiologist. The lower pole of the left kidney was targeted and 2 biopsy
passes performed.
SEDATION: Moderate sedation was provided by administering divided doses of
Fentanyl and Versed throughout the total intra-service time of 12 minutes
during which the patient's hemodynamic parameters were continuously monitored
by an independent, trained radiology nurse.
IMPRESSION:
Ultrasound guidance for percutaneous left kidney biopsy.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ male with acute renal failure. Eval for obstruction
or hydro.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 13.9 cm. The left kidney measures 14.2 cm. There
are small shadow forming echogenic foci in the left kidney likely representing
nonobstructive calculi. There is no hydronephrosis.
The bladder is moderately well distended and normal in appearance. Both
ureteral jets are visualized.
IMPRESSION:
1. No hydronephrosis. Both ureteral jets are visualized.
2. Nonobstructive nephrolithiasis of the left kidney.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ w/ HTN, HLD, ___ (Plavix), MI ___ process, clean
coronaries ___ and T2DM who p/w two weeks of cough and dyspnea and found to
have pulmonary infiltrates and acute kidney injury concerning for GN.//
re-evaluate infiltrates. Considering bronch if infiltrates still persist
TECHNIQUE: Multi detector CT of the chest was performed without the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 40.2 cm; CTDIvol = 15.1 mGy (Body) DLP = 605.3
mGy-cm.
Total DLP (Body) = 605 mGy-cm.
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: The multiple small mediastinal lymph nodes. A right paratracheal
node measures 12 mm. A pre-vascular lymph node measures 10 mm. The
subcarinal nodes measure up to 1.9 cm. There is moderate cardiomegaly. There
is moderate coronary artery calcification. The main pulmonary artery measures
3.7 cm. The aorta is normal in caliber. There is mild atherosclerotic
calcification involving the descending thoracic aorta. There is no
pericardial effusion
PLEURA: There are small bilateral effusions right greater than left.
LUNG: There are multifocal bilateral parenchymal opacities in a bronchus
centric distribution a predominantly within the right upper lobe but also
within both lower lobes. Findings are suggestive of a multifocal pneumonia.
There is mild interstitial edema.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine.
UPPER ABDOMEN: Limited sections through the upper abdomen shows evidence of
splenomegaly. No focal liver lesions are seen.
IMPRESSION:
Bronchus centric opacities in the right upper lobe and both lower lobes
concerning for multifocal pneumonia.
Small bilateral effusions and mild interstitial edema.
Small mediastinal lymph nodes could be reactive.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Acute kidney failure, unspecified
temperature: 98.1
heartrate: 72.0
resprate: 18.0
o2sat: 97.0
sbp: 200.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | PATIENT SUMMARY
===============
___ w/ HTN, HL, RA, DM, TIA presenting after recent episode
likely community-acquired pneumonia s/p azithromycin with
improvement who presented with persistent cough and dyspnea and
found to have bilateral lung opacities and acute kidney injury
with nephrotic-range proteinuria.
ACTIVE ISSUES
=============
#) ACUTE KIDNEY INJURY
On admission, patient noted to have acute kidney injury with a
creatinine of 3.1 (baseline normal, 0.5). Renal ultrasound
normal. Nephrology consulted. Urine sediment showed few
cellular casts. Urine protein/creatinine ratio 10.3. CRP 59
and ESR 119. Other workup remained unrevealing (negative ___
and ANCA, normal C3, C4). During admission, creatinine
improved. The etiology of the acute kidney injury remained
unclear. It is possible that the proteinuria is secondary to
diabetes, and that he developed acute kidney injury secondary
to post-streptococcal glomerulonephritis, or pre-renal
azotemia, and that the cellular casts were related to the
hypertension. Very low suspicion for pulmonary-renal syndrome.
Underwent kidney biopsy on ___. The patient was discharge
while awaiting pathology results because it was felt that his
kidney function had stabilized and he was appearing clinically
well without symptoms. Needs outpatient follow up with
nephrology.
#) PULMONARY INFILTRATES
Patient was recently diagnosed with community-acquired
pneumonia and completed a course of azithromycin and presented
with persistent dyspnea and productive cough. Imaging was
notable for nodular pulmonary consolidations with associated
ground-glass opacities. Repeat CT scan showed persistent
radiographic evidence of multifocal nodular opacities in RUL
and LLL, which prompted bronchoscopy for further evaluation.
BAL was only notable for diffusely edematous airways without
focal lesions or hemorrhage. BAL cell count showed atypical
cells but cytology was negative for malignancy. The patient
symptomatically improved during admission and did not receive
antibiotics. The symptoms and infiltrates were thought to be
related to community acquired pneumonia. Patient will need
repeat outpatient CT chest to evaluate the infiltrates in ___
weeks, and outpatient follow up with pulmonology.
#) HYPERTENSIVE URGENCY:
During admission, patient was found to have hypertensive
urgency with systolic blood pressure up to 200 but the patient
remained asymptomatic without evidence of end organ damage.
Per the patient, he has longstanding hypertension, and rarely
had blood pressure readings less than 150. During admission,
anti-hypertensives were adjusted given the setting of acute
kidney injury. Lisinopril was held. Received home furosemide,
amlodipine and spironolactone. Metoprolol was transitioned to
labetalol for better blood pressure control. Also started on
hydralazine. There was aggressive blood pressure management to
reduce the bleeding complication risk of the renal biopsy.
Patient should have further outpatient workup of resistant
hypertension, and should have monitoring of blood pressure and
adjustment of anti-hypertensives as appropriate.
#) CHEST PAIN
During admission, patient reported intermittent pleuritic chest
discomfort. EKG showed stable ST elevations that were
attributed to repolarization in anterior leads. Cardiac
enzymes showed only slight elevation of troponin and normal
CK-MB. Per the patient's report, cardiac catheterization one
year previously showed no evidence of CAD. The
characterization of the pain, and the clinical picture was not
felt to be consistent with ACS. Could consider further
outpatient workup with stress test and TTE.
#) ANEMIA
Patient found to have new hypoproliferative anemia with
hemoglobin ___. No evidence of bleeding. Iron studies were
normal. The etiology remained unclear during admission but
patient remained hemodynamically stable, with stable hemoglobin
and did not require a transfusion so it was felt that further
workup could be pursued in the outpatient setting.
#) CONCERN FOR MYOSITIS
Noted during admission patient had evidence of myositis
(elevated CK, mildly elevated troponin T, and elevated
CRP/ESR). No associated myalgias or weakness. Differential
includes hypothyroidism (TSH elevated and FT4 low, needs repeat
thyroid studies as outpatient), drug-induced (was on
gemfibrozil and rosuvastatin (which were both held during
admission) or autoimmune. Patient needs further workup as an
outpatient. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Labetalol
Attending: ___.
Chief Complaint:
weakness; ankle pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ man with a history of dementia,
HTN, HLD, T2DM (A1c 6.2% ___, heart block s/p PPM, prostate
cancer with mets to the bladder complicated by prior bladder
outlet and ureteral obstructions requiring ureteral stenting and
foley. History was obtained from the patient and his son, ___.
He was referred in for anemia after going to his PCP for right
ankle pain beginning last night. He did fall backwards last
night on his hands and left side but did not injure his ankle.
Of note, he recently completed a prednisone taper and has a
chronic indwelling foley.
In the ED, initial vitals were: T: 97.8 HR: 94 BP: 148/66 RR: 18
Sp02: 100% RA. He was given Unasyn for possible right ankle
ceullitis. He was guaiac negative. His labs were notable for a
HgB of 7.5, mild white count to 10.2, and INR of 1.2. UA was
significant for hematuria and bacteruria (? from foley bag)
On the floor, he endorsed "feeling weak" for the last 2 days
with pain in his ankle which was gradual in onset. Per his son,
he was noted to have lower blood sugars these last two days to
50 (usually runs 90-100's in the AM). He was given orange juice
with minimal improvement. He endorses feeling well prior to
these two days. Hematuria began this morning as the family noted
it in the foley bag. Denied fevers, chills, chest pain,
abdominal pain, or pain at the foley site. He also denies any
urinary symptoms. Denies feeling lightheaded.
Past Medical History:
bladder cancer s/p Transurethral Resection Bladder ___
prostate cancer Dx ___
HTN
HLD
DM2 with nephropathy
anemia
dementia
glaucoma - open angle
cataracts
osteoarthritis
.
Past Surgical (Ocular) Hx:
S/P pciol/filter od ___
S/P Pterygium removal od ___
S/P Pterygium removal os ___
PTERYGIUM OD [REGROWTH] ___
S/P LTP od #1 ___
Social History:
___
Family History:
Parents deceased. Mother had pacemaker, died at age ___ from
surgical complications. Father had CAD, adult-onset DM, stroke,
Alzheimer's. Has 2 sisters who are healthy. No FHx of MI or
arrhythmia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T: 99.0 BP: 164/81 HR: 89 RR: 17 Sp02: 99 on RA
GEN: Elderly man lying in bed, oriented to person and place, but
not to time.
HEENT: MMM, no LAD, oropharynx with poor dentition but otherwise
normal appearing.
PULM: On RA, good air exchange, no increased work of breathing,
no wheezes, rales or ronchi
CV: Normal S1,S2, regular rate, no murmurs, rubs or gallops,
distal pulses intact (DP, ___, and radial)
ABD: Soft, non-tender, non-distended.
GU: Foley in place, draining bloody urine.
EXT: Warmth and swelling on right foot with point tenderness
near navicular bone on the medial side. Range of motion normal
bilaterally.
NEURO: CN II-XII intact, strength ___ in upper and lower
extremities except for 4+/5 in affected right ankle.
DISCHARGE PHYSICAL EXAM:
Vital Signs: T: 99.5 BP: 144/59 HR: 99 RR: 16 Sp02: 100 on RA
I/O: ___ for 24 hours, -1300 since MN
GEN: Elderly man lying in bed, oriented to person and place, but
not to time.
HEENT: MMM, oropharynx with poor dentition but otherwise normal
appearing.
PULM: On RA, good air exchange, no increased work of breathing,
no wheezes, rales or ronchi
CV: Normal S1,S2, regular rate, no murmurs, rubs or gallops,
distal pulses intact
ABD: Soft, non-tender, non-distended.
GU: Foley in place, urine darkened by blood.
EXT: Warmth and swelling on right foot with point tenderness
near navicular bone on the medial side. Range of motion normal
bilaterally.
NEURO: CN II-XII intact, strength ___ in upper and lower
extremities except for 4+/5 in affected right ankle
Pertinent Results:
ADMISSION LABS:
___ 05:55AM BLOOD WBC-8.7 RBC-3.13* Hgb-9.2* Hct-29.3*
MCV-94 MCH-29.4 MCHC-31.4* RDW-14.9 RDWSD-51.3* Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-93 UreaN-18 Creat-1.1 Na-138
K-4.0 Cl-104 HCO3-23 AnGap-15
___ 05:55AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-8.7 RBC-3.13* Hgb-9.2* Hct-29.3*
MCV-94 MCH-29.4 MCHC-31.4* RDW-14.9 RDWSD-51.3* Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-93 UreaN-18 Creat-1.1 Na-138
K-4.0 Cl-104 HCO3-23 AnGap-15
___ 05:55AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
PERTINENT IMAGING:
___ FOOT AP,LAT & OBL RIGHT:Subtle lucency through the
distal tuft of the big toe may represent a nondisplaced fracture
if this is site of clinical concern. No acute fracture seen
elsewhere.
MICROBIOLOGY:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. brimonidine 0.2 % ophthalmic BID
3. Pravastatin 40 mg PO QPM
4. Tamsulosin 0.4 mg PO QHS
5. Xtandi (enzalutamide) 4 capsules oral DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Glargine 16 Units Breakfast
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Pravastatin 40 mg PO QPM
4. Tamsulosin 0.4 mg PO QHS
5. Xtandi (enzalutamide) 4 capsules oral DAILY
6. Glargine 16 Units Breakfast
7. brimonidine 0.2 % ophthalmic BID
8. 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 #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Weakness
Anemia
Right foot contusion
Urinary Tract Infection
Secondary Diagnoses:
Diabetes Type II
Hypertension
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
INDICATION: History: ___ with right foot pain and swelling. // Evaluate for
fracture
TECHNIQUE: Three views of the right foot
COMPARISON: None.
FINDINGS:
Subtle lucency through the distal tuft of the first digit may represent a
nondisplaced fracture. No acute fracture is seen elsewhere. There is a small
plantar calcaneal spur.
IMPRESSION:
Subtle lucency through the distal tuft of the big toe may represent a
nondisplaced fracture if this is site of clinical concern. No acute fracture
seen elsewhere.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Anemia
Diagnosed with Cellulitis of right lower limb, Hematuria, unspecified, Anemia, unspecified, Urinary tract infection, site not specified
temperature: 97.8
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 66.0
level of pain: 8
level of acuity: 2.0 | ___ year old man with a history of Type II Diabetes, HTN,
prostate cancer with mets to the bladder c/b prior outlet
obstruction requiring chronic foley placement. He referred from
his PCP ___ "feeling weak" and having gradual onset ankle pain
and found to anemic to 7.5 (8.7 on ___. Ankle XR showed no
fracture and he was able to bear weight well. Hemoglobin
downtrended to 6.9 for which he was transfused 2 units. No
evidence of hemolysis; ___ Oncology assessed, likely due to
anemia of chronic disease, possible bone infiltration from known
prostate cancer. His urinary tract infection will be treated
with 5 days antibiotics total (3 days outpatient with bactrim).
Urine culture at ___ significant only for fecal contamination.
ACUTE ISSUES:
# Right ankle pain: Diffuse mild swelling on right ankle with
point tenderness near the navicular bone. X-ray was unrevealing.
Passive motion without significant pain. Suspicion was low for
gout or septic arthritis given minimal pain with motion and no
joint effusion. He was able to ambulate normally on the ankle by
the day of discharge.
# Normocytic Anemia: Hemoglobin ___ at baseline per outpatient
records. Anemia is likely multifactorial relating to hematuria,
underlying malignancy and chemotherapy. Guaiac negative x 2--
low suspicion for GI Bleed. Not on anticoagulation, no
hemodynamic instability and thus there was low suspicion for
retroperitoneal bleed. HgB 6.9 on ___. Labs concerning for
anemia of chronic disease. Hematuria unlikely sole cause given
decrease of frankly bloody output. Given 2 units packed red
blood cells with appropriate response to hemoglobin 9.2 on the
day of discharge.
# UTI/Hematuria: Pyuria and hematuria concerning for catheter
associated infection or possibly secondary to malignancy.
Catheter replaced on day of admission. Given Unasyn in the ED
and ceftriaxone on the floor. Repeat urinalysis confirmed UTI,
hematuria resolving on ___. Urine culture at ___ showed
fecal contaminant and was treated with Bactrim as an outpatient
CHRONIC ISSUES:
# Dementia: was at baseline per family while in patient,
oriented to self and location but not time.
# Hypertension: Not currently on any treatment per outpatient
physician. Blood pressures ranged from 140's to 160's.
# DM II: continued on Glargine 16 AM and on insulin sliding
scale.
# Ophtho: home drops continued
# Prostate cancer: home Xtandi continued. foley as per above
Transitional Issues:
[ ] Bactrim DS BID continued through ___
[ ] Follow-up with PCP
[ ] Follow-up with hematology
[ ] Please arrange blood transfusions as outpatient
CODE: FULL
CONTACT: ___ (Son) C: ___ H: ___ |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Captopril / Zestril
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - CABGx4
___ - Cardiac Catheterization
History of Present Illness:
___ M HTN, pre-diabetes, prior DVTs
on coumadin, CKD (baseline creat 1.2-1.5), remote hx/o colon
cancer who presents from PCP's office with chest pain.
The patient complaints of intermittent chest pain over the past
2
days. The pain is described as sharp/knife-like & ___ in
severity. The pain occurs on the left side & extents to the
upper
L arm. The pain is provoked by standing from laying or sitting
upright. He has been having ___ episodes of pain daily (each
lasting ___ minutes) over the past 2 days. The patient's most
recent episode of pain woke him up from sleep. There has been ___
associated nausea, vomiting, or dizziness. There has been
associated diaphoresis & B/L UE shaking. He has never had any
prior episodes of this pain.
The patient has also had ___ weeks of upper abdominal pain which
is described as a crampy, bloated sensation across the upper
abdomen which has been relatively constant. This pain is not
affected by eating. It has not been relieved by Maalox. This
symptom has been evaluated by his PCP & the pt had an ultrasound
___ (which was normal). The patient also has BRBPR fairly
often
which is noted only when wiping. He attributes this to his known
hemorrhoids. He notes 2 days of black stools.
Patient had ___ chest pain at the time of catheterization and
therefore was placed on nitroglycerin.
Past Medical History:
gout
Colon cancer
---> Polyps on screening ___ ___,
---> Subsequently found to be adenocarcinoma & high-grade
dysplasia
HTN
Pre-diabetes
VTE (2 prior DVTs in past ___ years) on coumadin
BPH
Social History:
___
Family History:
Premature coronary artery disease brother had CABG in his ___
Physical Exam:
Admission Physical Exam
Pulse: 49 Resp:16 O2 sat:100%2L
B/P ___
Height:5'7" 170cm Weight:97.5kg 215lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x]1+
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
___ Right:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right:- Left:-
Pertinent Results:
___ - Cardiac Cath
Coronary angiography: right dominant
LMCA:
LAD: 90% proximal, 90% mid, 40% diagonal
LCX: major bifurcation OM with 80% origin and 95% mid
RCA: 95% distal, 80% mid PDA
Assessment & Recommendations
1. Three vessel CAD best ___ for CABG.
2. Discussed with Dr ___ with tentative plans for CABG
tomorrow.
3. CCU for continued care on IV NTG.
.
___ ECHO
PRE-BYPASS:
The left atrium is dilated. ___ spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. ___ atrial septal defect is seen by 2D or color
Doppler. There is moderate regional left ventricular systolic
dysfunction with focalities in the apical especially lateral and
anterior walls. Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. ___ aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is ___ pericardial effusion. Dr. ___ was notified
in person of the results before surgical incision.
Post_Bypass:
Normal Right ventricular dysfunction.
LV appears normal with ___ focalities. LVEF 55%.
Intact thoracic aorta.
Mild MR. ___ TR.
___ other new findings.
___ 01:40AM BLOOD WBC-13.9* RBC-3.09* Hgb-9.2* Hct-29.5*
MCV-96 MCH-29.7 MCHC-31.1 RDW-15.7* Plt ___
___ 12:30PM BLOOD WBC-10.4 RBC-4.86 Hgb-14.9 Hct-46.5
MCV-96 MCH-30.7 MCHC-32.0 RDW-15.8* Plt ___
___ 01:40AM BLOOD ___
___ 02:38PM BLOOD ___ PTT-41.6* ___
___ 01:40AM BLOOD Glucose-110* UreaN-41* Creat-1.7* Na-135
K-3.8 Cl-96 HCO3-27 AnGap-16
___ 12:30PM BLOOD Glucose-103* UreaN-34* Creat-1.6* Na-129*
K-GREATER TH Cl-96 HCO3-27
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Terazosin 5 mg PO HS
6. Warfarin 2 mg PO DAILY16
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Terazosin 5 mg PO HS
2. Acetaminophen 650 mg PO Q4H:PRN temperature >38.0
3. Albuterol Inhaler 6 PUFF IH Q4H:PRN wheezing
4. Amiodarone 200 mg PO BID postop AFib
x 7 days, then decrease to 200 mg daily. Cardiology to reeval
thereafter
5. Aspirin EC 81 mg PO DAILY
6. Atorvastatin 80 mg PO HS
7. Warfarin 2 mg PO DAILY16
Resume home dosing/ Follow INR
___ MD to order daily dose PO DAILY16 postop AFib/Hx
DVT
9. Dextrose 50% 12.5 gm IV PRN glucose < 60
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Docusate Sodium 100 mg PO BID
12. Glucose Gel 15 g PO PRN hypoglycemia protocol
13. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
14. Heparin 5000 UNIT SC TID
15. Metolazone 5 mg PO DAILY
16. Metoprolol Tartrate 6.25 mg PO BID
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*15
Tablet Refills:*0
18. Pantoprazole 40 mg PO Q24H
19. Potassium Chloride 20 mEq PO DAILY
x 7 days
20. Senna 17.2 mg PO HS
21. Ciprofloxacin HCl 500 mg PO Q24H UTI Duration: 5 Days
22. Allopurinol ___ mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
24. Furosemide 40 mg PO DAILY Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease
gout
Colon cancer
---> Polyps on screening ___ ___,
---> Subsequently found to be adenocarcinoma & high-grade
dysplasia
HTN
Pre-diabetes
VTE (2 prior DVTs in past ___ years) on coumadin
BPH
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, ___ erythema or drainage
Leg Left - EVH healing well, ___ erythema or drainage.Necrotic
area on left shin
1+ edema
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with cad // r/o inf, eff
COMPARISON: No recent chest radiographs. Red with chest CT ___.
IMPRESSION:
Lungs are low in volume, probably clear, but better evaluated with
conventional chest radiographs at full inspiration. Heart size obscured by
the elevated diaphragm. No appreciable pleural effusion. No pneumothorax or
mediastinal widening.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG // FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___: ___
IMPRESSION:
In comparison with the study ___, there has been a CABG procedure
performed with intact midline sternal wires. Endotracheal tubes have lies
approximately 6 cm above the carinal. Right IJ catheter extends to the mid
portion of the SVC. Nasogastric tube extends well into the stomach. Left chest
tube is in place and there is no pneumothorax.
There are lower lung volumes. Mild indistinctness of pulmonary vessels raises
the possibility of some elevated pulmonary venous pressure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man s/p CABG // eval for pneumothorax s/p chest tube
removal
COMPARISON: Chest radiographs, prior to surgery on ___ and postoperatively
on ___.
IMPRESSION:
Patient has been extubated, probably accounting for slight increase in caliber
the cardiomediastinal silhouette and in increase in bibasilar atelectasis a
lower overall lung volumes are about the same, still quite low. Previous mild
interstitial edema has resolved. Small left apical pneumothorax has developed
following removal of the left thoracostomy tube and there has been increase in
the volume of small left pleural effusion.
Right jugular line ends in the region of the superior cavoatrial junction.
NOTIFICATION: Dr. ___ paged ___ to discuss the findings on
___ 18:09 minutes after discovery of the findings, ultimately reported
by telephone to ___ on ___ at 18:10
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Large left pneumothorax is associated with near-complete collapse
of the left lung, and the clinical team has already placed a left chest tube
to treat this finding by the time of this dictation on ___ (see
separately dictated post-chest tube placement radiograph under clip ___.
Cardiomediastinal contours are similar to the recent post-operative
radiograph. Prominent midsternal lucency could be a normal post-operative
finding or could reflect sternal dehiscence in this patient with recent
sternotomy. Widespread subcutaneous emphysema has worsened since the recent
radiograph. Small pleural effusions are present, left greater than right.
Radiology Report
PORTABLE CHEST ___
COMPARISON: Study of earlier the same date.
FINDINGS: Following placement of left-sided chest tube, a left pneumothorax
has substantially decreased in size with residual moderate left pneumothorax
with apical, lateral and basilar components. Hydropneumothorax is noted in
the basilar component. Additionally, pneumomediastinum is present as well as
worsening subcutaneous emphysema. With the improvement in the left
pneumothorax, there has been substantial improvement in left lung collapse
with residual partial atelectasis of the left lower lobe and lingula.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___.
FINDINGS: Left chest tube remains in place, with persistent small left apical
pneumothorax. Basilar hydropneumothorax shows less gas and slightly more
pleural fluid. Slight worsening of left retrocardiac atelectasis. Within the
right hemithorax, a small pleural effusion is new. Small amount of
pneumomediastinum is present, as well as marked bilateral subcutaneous
emphysema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p left ptx with ct in place // eval for ptx
IMPRESSION:
In comparison with the study ___, the previously described apical
pneumothorax is not definitely identified. The pectoral this is less
prominent than on the previous study. Left chest tube remains in place and
there is continued opacification at the bases consistent with small pleural
effusions and compressive atelectasis. Some indistinctness of pulmonary
vessels is consistent with elevated pulmonary venous pressure.
Radiology Report
INDICATION: ___ year old man // eval for pneumo
TECHNIQUE: Portable chest x-ray
COMPARISON: Multiple prior radiographs of the chest dated ___ to ___.
FINDINGS:
Portable semi upright radiograph of the chest demonstrates low lung volumes
resulting in bronchovascular crowding. The previously described left apical
pneumothorax is not definitely identified. Air outlining the left pectoral
muscle is unchanged. A left-sided PleurX catheter is present. There are small
bilateral pleural effusions with adjacent atelectasis, which have decreased
over the interval. Indistinctness of pulmonary vessels is consistent with
elevated pulmonary venous pressure.
IMPRESSION:
The previously described left apical pneumothorax is not definitely
identified.
Radiology Report
INDICATION: ___ year old man // eval for pneumo
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior radiographs of the chest dated ___ through
___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate low lung volumes
resulting in bronchovascular crowding. The low lung volumes accentuate the
cardiac silhouette. There are small bilateral pleural effusions. There is
adjacent atelectasis in the left base. Chest tubes project over the left
hemithorax. There is no definite pneumothorax. Subcutaneous emphysema has not
changed significantly over the interval. A right-sided internal jugular
central venous line and the distal SVC. Median sternotomy wires are in place.
Subcutaneous gas is present in the bilateral supraclavicular soft tissues.
IMPRESSION:
Small bilateral pleural effusions without evidence of pneumothorax.
Radiology Report
INDICATION: ___ year old man // eval for pneumo
TECHNIQUE: Portable chest x-ray.
COMPARISON: Multiple prior radiographs of the chest dated ___.
FINDINGS:
Portable semi upright radiograph of the chest demonstrates low lung volumes
with resulting bronchovascular crowding. These low lung volumes accentuate the
cardiac silhouette. There are small bilateral pleural effusions with adjacent
atelectasis. There has been interval removal of the left-sided chest tube.
There is no definite pneumothorax. Subcutaneous emphysema has not changed
significantly over the interval. A right-sided internal jugular central
venous line with the mid SVC.
IMPRESSION:
No definite pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p CABG/left pneumo // eval for pneumo
IMPRESSION:
In comparison with the study of earlier in this date, the cardiomediastinal
silhouette is unchanged. Again there is increased opacification at the left
base, consistent with atelectatic change. Blunting of the costophrenic angles
is unchanged. No evidence of pneumothorax.
Subcutaneous gas and gas in the supraclavicular region is again seen.
Radiology Report
INDICATION: ___ year old man s/p CABG, left chest removal >24hrs // eval for
pneumo
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and ___.
FINDINGS:
Subcutaneous emphysema persists but is diminishing over time. No distinct
pneumothorax or pneumomediastinum, however is evident. Small bilateral pleural
effusions also persist. Positioning of right-sided central venous catheter is
unchanged.
IMPRESSION:
No significant interval change compared to yesterday's study. .
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT BILATERAL
INDICATION: ___ year old man with hx DVT and Left lower extremity swelling //
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, superficial 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.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: 96.8
heartrate: 49.0
resprate: 16.0
o2sat: 100.0
sbp: 159.0
dbp: 64.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was admitted to the ___ on ___. He was found
to have had a myocardial infarction. Heparin was started. He was
taken to the cardiac catheterization lab where he was found to
have severe three vessel disease. Given the severity of his
disease, the cardiac surgical service was consulted for
assistance with his care. He was worked-up in the usual
preoperative manner. Vitamin K and FFP were given for an
elevated INR. Of note, Mr. ___ has a hx of colonic
adenocarcinoma s/p polypectomy with complete removal in ___ and
preoperatively was noted to have dark stools x 2 days and mild
abdominal pain. He was admitted with an NSTEMI/UA and severe 3
vessel disease on a nitro
gtt to the CCU. Gastroenterology was consulted for preop CABG
eval and recommendations. Per GI: ___ signs of active bleeding.
GI felt that his abdominal pain may have been a representation
of his coronary disease. Without clear signs of bleeding, and a
stable HCT there was ___ indication for endoscopic evaluation
prior to CABG.
On ___, Mr. ___ was taken to the operating room where
he underwent coronary artery bypass grafting to four vessels.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. Over the next
several hours, he awoke neurologically intact and was extubated.
He was gently diuresed towards his preoperative weight. He
developed hematuria and a three-way foley was placed to allow
for flushing of the catheter. His chest tubes were removed per
protocol. He developed atrial fibrillation with a controlled
ventricular response. On post-operative day two he was
transferred to the surgical step down floor. His coumadin was
restarted and his epicardial wires were removed. He was started
on low dose betablocker but developed pauses ___ sec long. He
was seen by the EP service who felt that his pauses were
compensatory pauses and would benefit from low dose amio and to
continue lopressor in an attempt to regain sinus rhythm.
Approximately 24 hours after chest tube removal, the pt reported
feeling short of breath. CXR was done and left pneumothorax was
evident. Chest tube was reinserted with lung expansion.
He had 2 failed voiding trials, foley replaced on ___ and per
urology they reccommended keeping the foley for 5 more days,
repeat voiding trial on ___, continue terazosin at pre-op
dose, follow with his own urologist if voiding issues continue.
He was started on Cipro for a positive UA. At the time of
discharge the Urine Cx was pending.
Pt has a necrotic area ~2cm on his left shin. With his history
of DVTs, chronic venous stasis changes, a left lower extremity
ultra sound was done. US was negative for DVT. Enzymatic
debridement gel and a wound care consult was done.
He continued to slowly progress and by the time of POD#6 he was
ready for discharge to ___ rehab. All follow up
appointments advised. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Egg White / House Dust
Attending: ___.
Chief Complaint:
"DOE with dry cough and n/v."
Major Surgical or Invasive Procedure:
1. CT-guided lung biopsy of the 1.9cm lesion in the RUL.
History of Present Illness:
___ year old homeless female presents to the ED with temp 100.3,
dyspnea on exertion and dry cough.
.
Patient has had intermittent dry cough since ___. At
the end of ___ she was treated with azithromycin x 5 days
for an atypical pneumonia. Patient was subsequently
hospitalized at ___ from ___ - ___ with persistent
cough, nightsweats and chills. Her CXR showed a RUL infiltrate
which was thought to be an old pneumonia, not treated with any
antibiotics. Initial concern for active TB, she had two
negative AFB sputums however samples were noted to be
concentrated with upper respiratory secretions. PPD was
negative. Follow-up chest film on ___ showed progression of
lung lesion, now identified as two discrete lung lesions, in
right upper vs lower lobe and lingula. Differential includes
fungus, mycobacterial and nocardia infection. Patient was
referred to pulmonary, per phone note from ___, and
scheduled for a CT chest without contrast tomorrow (___).
Patient complained of worsening chest tightness, sob and
nightsweats. She was advised to go to the ED if symptoms
persisted.
.
Patient reports Temp to 100.3 several days ago. She reports
that she had been feeling better until ___ when she had a
episode of nausea and NB NB vomitting. She also reports
worsening NS, chills and decreased activity tolerance. She
reports that she is usually able to go for 15 minute walks
without difficulty. Now she gets sob with about 5 minutes of
walking. She says that she had infections fairly frequently in
the past, but unsure of exact duration or location. She has a
h/o pna at age ___ but no other pulmonary issues. Her ROS is
also positive for vaginal discharge that she feels is from an
untreated BV infection. She denies CP per say but says she has
occasional parathesias in her chest. ROS is otherwise negative.
.
Had a negative HIV test in ___. Attempting to relocate to a
new shelter, reports high levels of mold.
.
ED: 98.6 108 120/60 16 100% RA; CTA Chest: neg for pe,
multifocal nodules in both lungs, cavitation in 2 nodules, ddx
includes multifocal infection, fungal vs septic emboli; patient
given unasyn, nafcillin, gent and ambisome - to cover
endocarditis and fungal etiologies
.
ROS:negative.
Past Medical History:
-Fibromyalgia and chronic pain
-Iron deficiency
-Depression, anxiety, PTSD
-Gonorrhea/chlamydia ___ and Gonorrhea ___
-Abnormal Pap in ___
-Bed bug bites
-h/o PNA
Social History:
___
Family History:
No family h/o lung pathology. Son with asthma.
Physical Exam:
Exam on admission:
VS: 98.2 117/69 94 18 100 RA
General: AAOX3 in NAD
HEENT: CN ___ grossly intact, MMM, oropharynx clear
Endo/Lymph: no obvious thyroid nodules, no LAd
CV: RRR, no RMG
Lungs: mild bibasilar crackles, left greater then right, equal
lung expansion
Abdomen: flat, not TTP, no HSM, active BS
Extremities:
UE: WWP, pulses equal, sensation intact, strength wnl
___: WWP, pulses euqal, sensation intact, strenght wnl
Derm: no obvious rashes, no stigmata of IE
Psych: mood and affect wnl
Exam at discharge:
T 97.6 BP 112/60 P ___ RR 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ blowing
systolic murmur best heard at LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Labs upon admission:
___ 02:58AM LACTATE-1.3
___ 02:43AM GLUCOSE-116* UREA N-14 CREAT-0.6 SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
___ 02:43AM WBC-6.7 RBC-4.05* HGB-13.3 HCT-38.2 MCV-95
MCH-32.8* MCHC-34.7 RDW-12.6
___ 02:43AM NEUTS-41.9* LYMPHS-45.7* MONOS-7.2 EOS-4.1*
BASOS-1.2
___ 02:43AM PLT COUNT-208
___ 02:20AM URINE HOURS-RANDOM
___ 02:20AM URINE UCG-NEGATIVE
___ 02:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 02:20AM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 02:20AM URINE MUCOUS-RARE
Pregnancy test negative
Labs prior to discharge:
___ 06:35AM BLOOD ESR-7
___ 06:00PM BLOOD ___ PTT-32.8 ___
___ 03:05AM BLOOD ___ PTT-29.0 ___
___ 06:00PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.5 Mg-2.1
___ 02:43AM BLOOD RheuFac-5
___ 02:43AM BLOOD ___
___ 06:35AM BLOOD CRP-2.0
___ 02:43AM BLOOD ANCA-NEGATIVE B
Aspergillus Galactomannin: Negative
Beta Glucan: Negative
ACE, serum: Negative
Micro:
Blood culture x4 negative, included fungal and AFB culture
.
Cryptococcal antigen: negative
.
TISSUE RUL NODULE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
.
AFB smear x3 negative
.
Reports:
___ CTA Chest: 1. No evidence of acute pulmonary embolism or
thoracic aortic pathology. 2. Multiple nodules in both lungs,
with suggestion of cavitation in a single nodule. The
differential considerations include multifocal infections, with
etiologies including fungal and Nocardia infection and
malignancy such as lymphoma. Septic emboli is considered
unlikely given the time course of progression. Recommended
biopsy for further evaluation.
___ CXR: Three nodules in the right upper lobe and left mid
lung, are
concerning for an infectious process including fungal and
nocardia infection. Malignancy is also in the differential.
Please refer to the CT chest performed on the same day for
further evaluation.
Biopsy results from Right lung lesion:
Lung nodule, needle core biopsy:
Pulmonary parenchyma with non-necrotizing granulomatous
inflammation, see note.
Note: AFB and GMS (fungal) stains are negative for organisms.
No polarizable material seen. The differential diagnosis
includes an infectious process and other causes of granulomatous
lung disease (sarcoidosis, etc...).
.
Cytology of right lung lesion:
NEGATIVE FOR MALIGNANT CELLS.
Bronchial cells, abundant macrophages, and structures
suggestive of granulomas.
.
___ TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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 appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Medications on Admission:
MEDROXYPROGESTERONE
PNV WITH ___ [___ PLUS] - 27 mg-1 mg Tablet
daily
ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth q6h prn
pain
NICOTINE - 14 mg/24 hour Patch 24 hr - apply 1 patch daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Depo-Provera Intramuscular
4. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1)
Tablet PO once a day.
5. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
8. fluticasone 250 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 disk* Refills:*1*
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Non-necrotizing granulmatous pneumonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with fever, chills, and recent pneumonia, to
rule out acute cardiopulmonary pathology.
COMPARISON: Chest radiograph ___.
PA AND LATERAL CHEST RADIOGRAPHS: The cardiomediastinal and hilar contours
are normal. A 1.0 cm right upper lobe , 1.3 cm right lower lobe and a 1.6 cm
left infrahilar nodules are appear similar to the earlier study of ___.
Compared to the prior study of ___, the lower lobe nodules are new. No
pleural effusion or pneumothorax is seen. No new lung nodules are detected.
IMPRESSION: Three nodules in the right upper lobe and left mid lung, are
concerning for an infectious process including fungal and nocardia infection.
Malignancy is also in the differential. Please refer to the CT chest performed
on the same day for further evaluation. The findings and biopsy
recommendations were discussed with ___ at 9:20 A.M.
Radiology Report
INDICATION: ___ woman with fever and dyspnea on exertion, to rule out
pulmonary embolism.
COMPARISON: Chest radiograph done on ___ and ___.
TECHNIQUE: MDCT helical images were acquired through the chest after
administration of 100 mL of Omnipaque intravenous contrast. Sagittal, coronal
and oblique reformats were generated and reviewed.
FINDINGS: The pulmonary arteries are well opacified up to subsegmental
levels, without evidence of acute pulmonary embolism. The thoracic aorta is
normal in course and appearance, without evidence of acute thoracic aortic
pathology. The heart and pericardium are normal.
The major airways are patent to subsegmental levels bilaterally. Multiple
pulmonary nodules with irregular margins are seen in both lungs. The largest
in the right upper lobe measures 1.9 x 1.7 cm (2:28) and the largest in the
lingula measures 2.0 x 1.5 cm. There is suggestion of cavitation within one
of the smaller nodules in the right lower lobe (2:54). Majority of these
nodules have vessel traversing through the lesion. Small reactive right and
left hilar nodes are present. No significant axillary or mediastinal
adenopathy is seen. Residual thymic tissue is present.
No pleural effusion or pneumothorax is seen. This study is not tailored for
evaluation of the subdiaphragmatic organs. Within this limitation, the imaged
upper abdomen is unremarkable.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection or
malignancy are detected.
IMPRESSION:
1. No evidence of acute pulmonary embolism or thoracic aortic pathology.
2. Multiple nodules in both lungs, with suggestion of cavitation in a single
nodule. The differential considerations include multifocal infections, with
etiologies including fungal and Nocardia infection and malignancy such as
lymphoma. Septic emboli is considered unlikely given the time course of
progression. Recommended biopsy for further evaluation. The above findings and
recommendation were discussed with ___ at 9:20 A.M on ___.
Radiology Report
PROCEDURE: CT-guided lung nodule biopsy.
OPERATORS: Dr. ___ imaging fellow) and Dr. ___
(radiology attending). Dr. ___ was present for the entire duration of the
procedure and personally supervised it.
COMPARISON STUDY: CTA of the chest dated ___.
INDICATION: ___ female with multiple pulmonary nodules. Request
CT-guided percutaneous biopsy to assess for lymphoma, TB or other infectious
source or sarcoidosis.
PROCEDURE: After explaining the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The
patient was brought to the CT suite and was placed in a prone position on the
CT table. A preprocedure timeout was performed using three unique patient
identifiers as per standard ___ protocol.
Limited preprocedure CT images of the upper chest was performed for purposes
of skin entry site localization. The peripherally located large nodule in the
right upper lobe was targeted. The nodule measured approximately 2.0 x 1.8 cm
in size (2, 47). The skin over the posterior right upper thoracic wall was
prepped and draped in usual sterile fashion. 1% lidocaine was used to
anesthetize the skin, subcutaneous soft tissues and parietal pleura. A
17-gauge coaxial needle was advanced under CT fluoroscopic guidance into the
peripheral aspect of the lesion. A single 18-gauge core biopsy sample was
then obtained. The patient immediately started coughing up and there was an
episode of hemoptysis with the patient coughing up to ___ mL of slightly
darkish colored blood. Patient remained hemodynamically stable. Repeat CT
fluoroscopic images demonstrated only a small quantity of perilesional
hemorrhage and no evidence of pneumothorax. The coughing and hemoptysis
subsided. Another biopsy was deemed necessary for the requested
microbiological and pathological studies. The 18-gauge core biopsy gun was
introduced again into the lesion and another core biopsy sample was obtained
with needle directed directly into the lesion. The patient immediately had
another episode of coughing with significant hemoptysis of approximately
150-160 cc of slightly darkish colored blood. The needle was removed
immediately and the patient was placed in right-side dependent position.
There was continued hemoptysis. The patient's hemodynamic parameters were
stable throughout the episode and the pulmonary and critical care service and
the MICU team was immediately consulted. Repeat CT images demonstrated no
evidence of a pneumothorax with only minimal quantity of perilesional
hemorrhage. There were no pleural fluid collections.
We continued to observe the patient in the right lateral decubitus position
for another 30 minutes. The patient continued to remain hemodynamically
stable. The hemoptysis subsided over the duration of observation in the CT
suite. The patient was then transferred to the intensive care unit.
Moderate sedation was provided by administering divided doses of Versed (2 mg)
and Fentanyl (150 mcg) throughout the total intraservice time of 1 hour and 20
minutes during which the patient's hemodynamic parameters were continuously
monitored.
IMPRESSION: Technically successful CT-guided percutaneous core biopsy of a
nodule in the right upper lobe. Procedure complicated by massive episode of
hemoptysis. The patient was immediately placed in right lateral decubitus
position with stable hemodynamic parameters and continued subsidence of the
hemoptysis.
Pathology, cytology and microbiological results pending at this time.
Radiology Report
CLINICAL HISTORY: Significant hemoptysis status post CT-guided biopsy of
right upper lobe lesion.
CHEST: There are low lung volumes, particularly on the right, which is
associated with a right pleural effusion. The right upper nodule is now
hazier, consistent with post-biopsy state. No pneumothorax is identified.
Allowing for the differences in lung expansion, the left lung remains
unchanged.
Radiology Report
CLINICAL HISTORY: Status post right-sided lung biopsy. Evaluate for
pneumothorax.
CHEST: No pneumothorax is identified. The opacity at the site of biopsy,
small right effusion, no change since prior chest x-ray.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: N/V, CHILLS
Diagnosed with OTHER LUNG DISEASE NEC, MYALGIA AND MYOSITIS NOS
temperature: 98.6
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | ___ year old woman with history of pneumonia and bronchitis as a
child, recent history of presumed right upper lobe pneumonia
treated with subsequent improvement but persistence of symptoms
(dry cough, fatigue, night sweats, chills, shortness of breath
on exertion), found to have progressive pulmonary nodules
(increasing in size and number), now s/p CT guided biopsy with
significant ___ transferred to ICU for monitoring.
.
# Hemoptysis: ___ cups of hemoptysis acutely during CT guided
biopsy of the right lung. Patient remained hemodynamically
stable, transferred to the FICU with continued intermittent
scant hemoptysis. 2 large PIVs were maintained and patient was
T&S'd. Hct stable at 39, satting 100% on RA. Patient was kept on
her right side (the side of the biopsy) and kept NPO. IP and ___
were consulted and requested her transfer to the ___ for
monitoring, should she need intervention. Repeat CXR showed new
right pleural effusion, right upper nodule now hazier,
consistent with post-biopsy state, no pneumothorax identified.
Patient was trasnferred ___ for further monitoring. She was
hemodynamically stable throughout the rest of her hospital
course with resolution of hemoptysis.
.
# Non-necrotizing granulomatous lung nodules: No fever or
leukocytosis. Biopsy and cytology results revealed
non-necrotizing granulomatous disease. Tissue culture was
negative, Staining for fungi and AFB were negative, serum fungal
markers negative, AFBx3 negative, Normal ESR, CRP, and
Rheumatoid factor, and ___ and ANCA negative. Based on these
findings in conjunction with imaging studies, infectious
etiologies, connective tissue disease/vasculidities, and
lymphoma were considered highly unlikely. The exact disease is
unclear at this time, but consideration was given to nodular
sarcoid, which although typically presents with hilar
lymphadenopathy and interstitial infiltrates can also present as
nodular lesions with minimal hilar lymphadenopathy.
.
# Pain: Patient is having post procedural pain which was
controlled initially with IV fentanyl, however was transtioned
to IV morphine and then oxycodone with good control.
.
# Anxiety: Managed with ativan prn.
.
# Fibromyalgia and chronic pain: Patient does not appear to be
managed with an SSRI at home.
.
# Iron deficiency anemia: not on iron supplements at home, no
evidence of iron deficiency on OMR. MCV is 95-98.
.
# Depression, anxiety, PTSD: not on outpatient meds.
.
.
Code: Full
TRANSITIONAL: Follow up on lesions. Given worsening of symptoms
at homeless shelter likely some component of allergies and
reactive airway disease. Recommend consideration of allergy
testing. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sildenafil
Attending: ___.
Chief Complaint:
left arm pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history of colon cancer s/p
resection, anemia of chronic disease, diabetes with chronic
kidney disease now on dialysis, coronary artery disease, left
cubital release and anterior transposition of left ulnar nerve
and gout presenting with left arm swelling and elbow/wrist pain
that began after inflation of a blood pressure cuff. No fevers
or chills. Similar pain in past compared to prior gout flares.
Seen in HCA today, triaged to ED given concern for cellulitis.
Past Medical History:
# CAD -- last cath ___ with stent of the distal RCA
# CHF -- TTE ___ with LVEF 45%. Normal LV cavity size with
regional hypokinesis. Mild mitral regurgitation with normal
valve morphology.
# Peripheral Vascular Disease
# Chronic Kidney Disease Stage 5 on HD ___
# Anemia of Chronic Disease
# Obstructive Sleep Apnea -- CPAP at night
# Colon cancer -- s/p resection (___)
# Erectile Dysfunction
# Right great toe amputation (___)
# Right Carotid Artery Stent
# Balloon Angioplasty
-- right anterior tibial artery
-- right dorsalis pedis artery
# Rectosigmoid cancer -- Low anterior resection (___)
# Right ulnar nerve decompression and anterior transposition
about the medal epicondyle
# Cubital tunnel release and anterior transposition of left
ulnar nerve
Social History:
___
Family History:
# Father: ___, CAD. Died of prostate cancer at age ___.
# Mother: Heart disease (died from ___ at age ___
Physical Exam:
VS: 98.5/97.7 143/51 62 18 100%RA, ___: 98, 164, 273, 233
General: thin but well-nourished gentleman lying comfortably in
bed. Alert and oriented, no apparent distress
HEENT: Normocephalic, atraumatic, EOMI, sclera anicteric, moist
mucous membranes
Neck: supple, no LAD
CV: regular rate and rhythm, no murmurs rubs or gallops, normal
S1 S2
Lungs: clear to auscultation bilaterally
Abdomen: thin, with catheters in LLQ and RUQ/chest for
peritoneal dialysis lessons, dressing are clean/dry/intact,
abdomen firm, non-tender non-distended
Ext: warm and well perfused, dressings in place on feet
bilaterally, 2+ DP pulses, 2+ radial pulses, no edema; right
hand with decreased mobility (per pt baseline) cannot extend
index finger; L elbow and wrist TTP with good ROM, no warmth or
erythema
Neuro: AAO x3, answers questions appropriately
Pertinent Results:
___ 09:26PM LACTATE-1.3
___ 09:15PM GLUCOSE-407* UREA N-11 CREAT-1.9*# SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
___ 09:15PM estGFR-Using this
___ 09:15PM CK(CPK)-82
___ 09:15PM WBC-5.1 RBC-3.88* HGB-10.6* HCT-33.5* MCV-87
MCH-27.4 MCHC-31.8 RDW-16.5*
___ 09:15PM NEUTS-70.5* ___ MONOS-8.5 EOS-1.5
BASOS-0.6
___ 09:15PM PLT COUNT-189
___ 09:15PM ___ PTT-38.1* ___
IMPRESSION: Small elbow joint effusion, soft tissue swelling
involving the
wrist and elbow as described, with periarticular erosion and
soft tissue
swelling involving the medial aspects of the fifth
metacarpophalangeal joint.
These findings are nonspecific but may reflect underlying
inflammatory
arthropathy, crystal arthropathy, or gout. Correlate
clinically.
ultrasound- no LUE DVT
all blood cultures negative, finalized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoprolol Tartrate 12.5 mg PO BID
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Prasugrel 10 mg PO DAILY
13. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prasugrel 10 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Ferrous Sulfate 325 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
13. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Principal Diagnosis
1. Acute gout flare
Secondary Diagnosis
1. Chronic kidney disease
2. Obstructive sleep apnea
3. Coronary artery disease
4. Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left arm swelling.
COMPARISON: None.
FINDINGS: Gray scale and color Doppler sonographic evaluation was performed of
the left upper extremity. Normal compressibility and flow is seen in the left
internal jugular, axillary, subclavian, basilic, paired brachial and cephalic
veins without evidence of DVT.
IMPRESSION: No left upper extremity DVT.
Radiology Report
EXAM: Radiographs of the left wrist and left elbow.
INDICATION: Severe wrist pain and swelling. Evaluation for septic joint,
versus crystal arthropathy, versus cellulitis.
COMPARISON: None.
FINDINGS:
LEFT ELBOW: AP and lateral views, shows mild soft tissue swelling around the
elbow, and a small elbow joint effusion. No fracture or dislocation. Dense
circumferential arthrosclerotic calcification involving the vessels along the
volar aspects of the elbow are noted. No chondrocalcinosis seen. No bony
erosions or joint degenerative change is seen.
LEFT WRIST: AP, lateral and oblique views, show moderate soft tissue swelling
surrounding the wrist, without fracture or dislocation seen. No joint
erosions involving the wrist seen. However, there is periarticular erosion
involving the medial aspect of the fifth metacarpophalangeal joint, with
adjacent mild soft tissue swelling (best seen on the AP view). Dense vascular
calcifications involving the distal forearm and wrist are noted.
IMPRESSION: Small elbow joint effusion, soft tissue swelling involving the
wrist and elbow as described, with periarticular erosion and soft tissue
swelling involving the medial aspects of the fifth metacarpophalangeal joint.
These findings are nonspecific but may reflect underlying inflammatory
arthropathy, crystal arthropathy, or gout. Correlate clinically.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L ARM SWELLING
Diagnosed with SWELLING OF LIMB
temperature: 98.4
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 166.0
dbp: 51.0
level of pain: 10
level of acuity: 2.0 | # Left upper extremity swelling: Most likely gout flare. Pain
began almost immediately after blood pressure cuff was cycling
on left arm ___ but was intermittent with inflation, swelling
developed gradually and pain is now almost constant. Swelling
concerning for upper extremity DVT, but LUE u/s with no evidence
of DVT. Cellulitis could be another possibility given warmth and
erythema, lack of response to cefazolin makes less likely but
organism may not be sensitive. Problems within the joint itself
are also possible. He has a history of gout with recent flare 2
months ago in bilateral knees (still on no medical management),
as well as history of bilateral swelling in elbows years ago
that resolved on its own, plus severe pain make a gout flare a
more likely possibility. After review of his stays here, he was
actually seen by rheumatology inpatient in ___ - his uric acid
was 7.2, inflammatory markers were elevated with ESR 85 and CRP
196.3; his knee was tapped and showed uric acid crystals, he was
started on prednisone 20 and noted significant improvement with
plan to taper the steroids by 5mg every 3 days with rheumatology
follow up. Septic joint should also be considered although
unlikely given involvement of multiple joints, fingers,
afebrile, no leukocytosis. Could also be nerve damage ___ trauma
of blood pressure cuff. Ortho unable to tap joint but agree that
gout is most likely.
- cont pred taper
- send RF, CCP
- rheum recs appreciated- will follow up as outpatient
- pain control
- hold abx
# CKD/HD: Currently on HD on a ___ schedule, followed by Dr.
___ at ___. His admission creatinine at 1.9 is
actually the best it's been in our system. Has a peritoneal
___ placed recently for anticipated PD in the near future,
not currently on PD.
- monitor creatinine
- continue nephrocaps 1 cap daily
- renal following
# Diabetes: now on prednisone.
- increase Lantus to 10u QHS
- QADHS finger sticks
- HISS while inhouse
# CAD:
- continue ASA 325, prasugrel 10mg, metoprolol tartrate 12.5
BID, atorvastatin 80
# HTN:
- monitor pressures
- continue home metoprolol tartrate 12.5 BID
#HLD:
- continue atorvastatin 80 daily
#OSA:
- CPAP overnight
# FEN: IVFs / replete lytes prn / regular diet
# PPX: heparin sq, bowel regimen
# ACCESS: PIV
# CODE STATUS: Full
# CONTACT: ___ (wife) - ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity rest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F w/PMHx CAD/PAD c/o l foot pain, l foot swelling and
pain times several days. her history is also notable for a
recent PCI followed by iliac and proximal profunda stenting.
she has had increasing pain over the toes of her left foot
for the past several days. She is noticed that the skin has
been blistering and that the areas are tender to touch. She
has otherwise had some occasional subjective fevers, no
other complaints. She is oriented to self and location, but
her memory and ability to recall her history is limited.
Past Medical History:
-CAD w/ 3VD
-Diabetes Type II
-Hypertension
-Hyperlipidemia
-Cardiomyopathy EF 25%
-Carpal tunnel syndrome
-Ganglion cyst
-Bilateral cataracts
-Fractured vertebrae after falling down flight stairs ___ yrs
ago
-Carotid stenosis
-moderate AS
-recent cholecystitis ___ treated non operatively
-PCI on ___ ___ groin access via the L femoral artery and 14
F Impella placed in the R femoral artery) with placement of 3
DES (DES to D1 DES x2 to LAD)
Social History:
___
Family History:
Premature coronary artery disease none
Father stroke at ___ - deceased
Mother kidney failure and pulmonary embolism - deceased
Physical Exam:
Vitals: T 98.7 HR 71 BP 146/48 RR 13 ___ 100RA
General: Patient is awake, oriented to self and place, however
somewhat confused but this is baseline.
CV: NRRR
Lungs: CLAB
Abd: Soft, nontender, no masses or ttp.
Extremities: R: P/D/D/D L: P/D/D/D. Left toes and distal aspect
of left foot bluish-tinged, warm, however with some skin
blistering. Tissue not presently infected.
Pertinent Results:
___ 05:45AM BLOOD WBC-7.0 RBC-2.58* Hgb-7.5* Hct-23.9*
MCV-93 MCH-29.1 MCHC-31.4* RDW-14.2 RDWSD-48.2* Plt ___
___ 06:45AM BLOOD WBC-7.4 RBC-2.50* Hgb-7.2* Hct-22.9*
MCV-92 MCH-28.8 MCHC-31.4* RDW-14.2 RDWSD-47.4* Plt ___
___ 06:40AM BLOOD WBC-7.2 RBC-2.53* Hgb-7.4* Hct-23.2*
MCV-92 MCH-29.2 MCHC-31.9* RDW-14.3 RDWSD-48.0* Plt ___
___ 07:40PM BLOOD WBC-10.1* RBC-2.72* Hgb-8.0* Hct-24.9*
MCV-92 MCH-29.4 MCHC-32.1 RDW-14.4 RDWSD-48.2* Plt ___
___ 07:40PM BLOOD Neuts-63.6 ___ Monos-9.2 Eos-5.5
Baso-1.1* Im ___ AbsNeut-6.40* AbsLymp-2.04 AbsMono-0.92*
AbsEos-0.55* AbsBaso-0.11*
___ 03:59AM BLOOD PTT-66.2*
___ 04:51PM BLOOD PTT-64.7*
___ 10:55AM BLOOD ___ PTT-58.5* ___
___ 02:05AM BLOOD PTT-67.5*
___ 07:33PM BLOOD PTT-61.5*
___ 05:45AM BLOOD Plt ___
___ 02:46PM BLOOD PTT-54.0*
___ 06:45AM BLOOD Plt ___
___ 11:16PM BLOOD PTT-80.7*
___ 05:15PM BLOOD PTT-75.6*
___ 06:40AM BLOOD PTT-83.9*
___ 06:40AM BLOOD Plt ___
___ 01:12AM BLOOD PTT-150*
___ 07:40PM BLOOD Plt ___
___ 07:40PM BLOOD ___ PTT-38.2* ___
___ 05:45AM BLOOD Glucose-125* UreaN-22* Creat-0.8 Na-140
K-3.6 Cl-105 HCO3-26 AnGap-13
___ 06:45AM BLOOD Glucose-129* UreaN-31* Creat-0.9 Na-139
K-3.6 Cl-101 HCO3-25 AnGap-17
___ 06:40AM BLOOD Glucose-92 UreaN-39* Creat-1.0 Na-137
K-3.6 Cl-101 HCO3-25 AnGap-15
___ 07:40PM BLOOD Glucose-110* UreaN-42* Creat-1.1 Na-137
K-3.9 Cl-99 HCO3-26 AnGap-16
___ 07:40PM BLOOD ALT-28 AST-32 AlkPhos-81 TotBili-0.4
___ 05:45AM BLOOD Phos-4.0 Mg-2.1
___ 06:45AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8
___ 06:40AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
___ 07:40PM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.6* Mg-1.9
___ 07:08AM BLOOD Lactate-1.0
___ 07:55PM BLOOD Lactate-1.4
___ DUPLEX MAP
Final Report
INDICATION: ___ year old woman with LLE rest pain x2 days // ?
suitable
conduit for bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging
of bilateral
saphenous veins was performed.
COMPARISON: ___
FINDINGS:
RIGHT:
The right great saphenous vein is patent. The vein measures 2.8
mm proximally
and 2 point mm distally. The right small saphenous vein is
patent. The vein
measures 1.8 mm proximally and 2.2mm distally. Additional
measurements are
available on PACS.
LEFT:
The left great saphenous vein is patent. The vein measures 3.9
mm proximally
and 2.3 mm distally. The left small saphenous vein is patent.
The vein
measures 2.2 mm proximally and 2.2mm distally. Additional
measurements are
available on PACS.
IMPRESSION:
Patent bilateral great and small saphenous veins.
Medications on Admission:
[SEE ADMISSION H AND P]
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
6. Gabapentin 300 mg PO QHS
7. Metoprolol Succinate XL 37.5 mg PO DAILY
8. Torsemide 10 mg PO DAILY
9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
10. NPH 3 Units Breakfast
NPH 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Enoxaparin Sodium 90 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin [Lovenox] ___ mg/mL ___ mL SC once a day Disp
#*20 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral lower extremity claudication
Peripheral vascular disease
Discharge Condition:
Mental Status: Confused - sometimes. At baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: History: ___ with severe PAD, with cellulitis, t 101.5, pain of L
toes // subq air?
TECHNIQUE: Three views of the left foot, two views of the left ankle, and
three views of the left toes.
COMPARISON: None
FINDINGS:
Hammertoe deformities of the second through fifth toes makes there evaluation
suboptimal. Given this, no definite cortical destruction is seen. There is
no specific findings of soft tissue gas. Degenerative changes are seen at the
TMT joints. There is a plantar calcaneal spur. Extensive vascular
calcifications are seen. No acute fracture or dislocation is seen.
IMPRESSION:
No evidence of soft tissue gas.
Radiology Report
INDICATION: ___ year old woman with LLE rest pain x2 days // ? suitable
conduit for bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
saphenous veins was performed.
COMPARISON: ___
FINDINGS:
RIGHT:
The right great saphenous vein is patent. The vein measures 2.8 mm proximally
and 2 point mm distally. The right small saphenous vein is patent. The vein
measures 1.8 mm proximally and 2.2mm distally. Additional measurements are
available on PACS.
LEFT:
The left great saphenous vein is patent. The vein measures 3.9 mm proximally
and 2.3 mm distally. The left small saphenous vein is patent. The vein
measures 2.2 mm proximally and 2.2mm distally. Additional measurements are
available on PACS.
IMPRESSION:
Patent bilateral great and small saphenous veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Foot pain, L Foot swelling
Diagnosed with Cellulitis of left toe
temperature: 101.5
heartrate: 61.0
resprate: 16.0
o2sat: 99.0
sbp: 139.0
dbp: 61.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ y/o F w/PMHx CAD/PAD who presented to the ED on
___ at the ___. Presenting
complaints included left and right foot pain at rest
(left>>>right) with left toes and inferior distal aspect of the
foot discoloration (bluish-tinge) and blistering. She reported
that the duration of all of these symptoms was ___ weeks or
more. She was hemodynamically stable and afebrile at the time of
admission. Of note, she is oriented to self and location, but
her memory and ability to recall her history is limited.
Following admission she was started on heparin gtt titrated to
___ and also underwent serial pulse exams. She was found to
have bilateral dopplerable pulses at her DP/PTs and this
remained consistent throughout the course of her
hospitalization. At the time of admission she was found to have
a positive UA (asymptomatic) and was treated with a 3 day course
of cipro for presumed UTI. She underwent vein mapping/duplex
studies of her bilateral lower extremities and was found to have
significantly reduced flow to the LLE. She underwent left CIA
stent (non-drug eluting) x3 on ___ without complication.
She resumed normal diet, ambulation, and home medications the
following day, and was able to void following the
discontinuation of her foley catheter. Her heparin gtt was
resumed and again target was 60-80. She progressed well and was
ultimately discharged back to her nursing facility on ___
in the evening. She was pre-oped by anesthesia and surgical
consent for fem-pop bypass was obtained. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tegretol / Keppra / Dilantin Kapseal / Erythromycin Base /
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin ER
/ prednisone / Quinolones
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with h/o GBM s/p resection, cyberknife and temozolomide
in ___, last treatment with Temozolomide in ___ and also h/o
NSCLC s/p stereotactic radiosurgery, who presents with seizures.
The patient reports she last had seizures in ___. At that
time seizures were characterized as sensory only (numbness).
Now pt describes RLE twitching that makes her whole body move.
This first happened at 5pm today and lasted about 10 minutes,
since then she has had repeat episodes, with similar quality but
lasting less each time to the point now that are happening every
___ minutes lasting seconds to 1 minute. Pt was sent to ED for
seizures and has had w/u for metabolic and infectious causes but
has not received any additional treatment yet. She denies any
LOC, bowel, bladder incontinence during the episodes and she
feels ok with no post ictal state after the episode. Pt also
denies HAs, numbness, focal weakness, visual changes, problems
with speech, memory. Last seizure was years ago, and possible L
sided sensory.
In ROS she alaso denies weight changes, fatigue, SOB, cough, CP,
palpitations, nausea, vomiting. Full ten point ROS was
otherwise negative.
Past Medical History:
Oncologic History
(1) a right temporal grade I meningioma resected by ___
___,
M.D. on ___,
(2) proton beam irradiation to a left parietal parasaggital
meningoma at ___ in ___,
(3) a left parietal gross total resection by Dr. ___ on
___,
(4) protocol with hypofractionated involved-field radiation +
Cyberknife boost + temozolomide from ___ to ___ to
4,005 cGy,
(5) Cyberknife radiosurgery to right parietal cavity to 2400 cGy
(800 cGy x 3 fractions) at 72% isodose line from ___ to
___,
(6) CT-guided left upper lobe lung biopsy on ___ showing
CK-7 and TTF-1 positive lung carcinoma, Stereotactic radiation
___
(7) shoulder surgery for bone spur on ___,
(8) had Portacath placement on ___, and
(9) status post 18 monthly adjuvant temozolomide cycles from
___ to ___.
PMH: (from Dr ___ note ___
Meningioma x2 (see below)
GBM (left parietal)
Hysterectomy
Hypertension
Diabetes mellitus, type 2
Left carotid endarterectomy
___ low back pain/congenital spondylolisthesis: L4-5
laminectomy ___ at ___.
Bunionectomy
Cataract surgery
Tubal ligation
Benign breast biopsies
Frequent UTI
COPD
Social History:
___
Family History:
Mother died at ___ from CHF
Physical Exam:
VSS
General: Awake, talkative, NAD.
HEENT: NCAT, MMM, OP Clear
Neck: Supple without meningismus
Pulmonary: Lungs CTAB, no w/r/r
Cardiac: RRR, no murmurs
Abdomen: soft, NT/ND,no organomegaly
Extremities: WWP, 2+ radial and DP pulses b/l
Skin: Mild bruising from venipunctures on R arm. Portacath site
C/D/I.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward in 15
seconds. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall ___ at 5 minutes. The pt. had good knowledge of current
events. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No tremors.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5- 5- 5- 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: Normal FNF bilaterally. No disdiadochokinesia
-Gait: deferred (patient to have EEG leads placed)
Pertinent Results:
___ 10:15PM WBC-10.7 RBC-4.89 HGB-14.2 HCT-41.1 MCV-84
MCH-29.0 MCHC-34.5 RDW-15.4
___ 10:15PM NEUTS-75.8* LYMPHS-17.9* MONOS-4.0 EOS-1.8
BASOS-0.5
___ 10:15PM PLT COUNT-182
___ 07:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___:15PM GLUCOSE-102* UREA N-14 CREAT-0.9 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 10:15PM CALCIUM-10.4* PHOSPHATE-3.2 MAGNESIUM-1.___ WET READ:
___ edema within the right hemisphere, compatible with
post-surgical
change. No new sulcal effacement or mass effect. No CT evidence
for acute
edema.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [VENTOLIN HFA] - (Prescribed by Other
Provider) - 90 mcg HFA Aerosol Inhaler - ___ puffs inhaled daily
as needed
ESTRADIOL [ESTRADERM] - (Prescribed by Other Provider) - 0.1
mg/24 hour Patch Semiweekly - 1 Patch(s) every 4 days NO
SUBSTITUTION
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 150 mg
Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider)
- 20 mg-25 mg Tablet - 1 Tablet(s) by mouth daily
METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 5 mg Tablet - 1 (One) Tablet(s) by
mouth at bedtime
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth three times a day
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
ZONISAMIDE [ZONEGRAN] - 100 mg Capsule - 4 Capsule(s) by mouth
at
bedtime
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider; ___) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
(One) Capsule(s) by mouth once a day
POTASSIUM - (Prescribed by Other Provider) - 99 mg Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation DAILY (Daily) as needed for shortness of
breath or wheezing.
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
7. irbesartan 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Estradiol Transdermal Patch 0.1 mg/24 hr Patch Weekly Sig:
One (1) patch Transdermal every 4 days.
9. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO TID (3 times a day).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
History of meningioma and glioblastoma multiforme
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS, ___.
HISTORY: ___ female with history of non-small cell lung cancer, now
with increased seizure activity.
FINDINGS: PA and lateral views of the chest were compared to previous exam
from ___. Right chest dual-lumen port is again seen with
catheter tip in the mid SVC. Clip seen within the left upper lobe with
associated linear opacity. There has, however, been interval resolution of
previously identified parenchymal opacities in the left upper lung. There is
no new region of consolidation or pleural effusion. Cardiomediastinal
silhouette is within normal limits. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: Interval resolution of the parenchymal opacity in the left upper
lung when compared to prior. No definite acute cardiopulmonary process.
Radiology Report
INDICATION: History of meningioma and seizures.
COMPARISON: MR available from ___ and PET-CT from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the head were obtained without
the use of IV contrast.
FINDINGS:
Again seen is right frontoparietal edema (2:20), unchanged since the ___ MR examination. The patient is post right lateral and posterior
craniotomies (2:13). There is no evidence of acute intracranial hemorrhage,
new mass, mass effect, or large vascular territorial infarction. There is no
shift of normally midline structures. The quadrigeminal and suprasellar
cisterns remain preserved. There is no acute fracture. The middle ear
cavities, mastoid air cells, and included views of the paranasal sinuses are
clear. A 12-mm left vertex meningioma (2:55) is unchanged.
IMPRESSION: No acute intracranial process. Unchanged right frontoparietal
edema.
Radiology Report
INDICATION: ___ woman with history of meningioma and GBM, now with
new focal seizures, evaluate for recurrent disease or progression.
COMPARISON: MR head on ___.
TECHNIQUE: MR of the head with and without contrast.
FINDINGS: Again seen are post-surgical changes in the right parietal lobe
with enhancement in the postoperative cavity and stable surrounding edema.
The known left parietal meningioma at the vertex with enhancement in the
adjacent brain parenchyma is unchanged. There are no new lesions. There is
no evidence of infarction or hemorrhage. There is no shift of normally
midline structures. The ventricles and sulci are unchanged in size and
configuration. The intracranial flow voids are maintained. Again seen is a
left maxillary sinus mucous retention cyst, unchanged.
IMPRESSION: No change compared to MR on ___ in enhancement in
the postoperative site of the right parietal lobe and the left vertex
meningioma with enhancement of the adjacent brain. No new lesions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SZ
Diagnosed with ABN INVOLUN MOVEMENT NEC, OTHER CONVULSIONS, HYPERTENSION NOS
temperature: 98.6
heartrate: 80.0
resprate: 10.0
o2sat: 97.0
sbp: 165.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ y/o F with h/o GBM s/p resection, cyberknife and temozolomide
in ___, last treatment with Temozolomide in ___ and also h/o
NSCLC s/p stereotactic radiosurgery, who presents with seizures.
.
# Seizures: Pt with past history of seizures, but had not had
since ___ and these are different in nature. HCT done in ER
did not show any new masses. Neuro Onc ___ contacted and
initially recommended VPA load with neurontin. She however
continued to have increased seizures, up to 10 per hour of right
leg tingling sometimes rising upwards to progress to twitching
of foot and trunk. She was transfered to the epilepsy service
for further EEG monitoring and med ajustment. We discontinued
neurontin and initiated scheduled ativan 1mg TID which
significantly decreased the frequency opf episodes. She was
tapered off the depakote prior to discharge. The preliminary EEG
results did not show any electrographic seizures during the
monitoring period, but official reports are pending. She was
discharged on ___ mg ativan to take BID in addition to her home
zonegran 400 mg at bedtime. She will follow up with her primary
epileptologist as outpatient shortly after discharge.
.
# Glioblastoma Multiforme: Last MRI in ___ did not show
recurrence, will repeat now due to new onset of seizures
.
# NSCLC: s/p stereotactic radiation to LUL in ___ with
recent PET CT in Fev ___ negative for recurrence.
.
# HLP: cont zocor
.
# HTN: cont lisinopril and HTCZ, ibersartan not on formulary
.
# GERD: cont PPI (tid) and reglan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin in D5W / Zosyn / ___ Containing
Attending: ___.
Chief Complaint:
altered mental status and cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with deep brain stimulator, hx of L MCA ischemic stroke,
presents for evaluation of AMS since this AM, approx. 0800, from
nursing home. Patient is ___ speaking only so could not get
good history from him this AM. Per our ED translator he is very
confused.
Per nursing home, pt was lethargic this morning, not able to get
up from his bed. At baseline, he can walk around with a walker.
At baseline he can respond to questions, but this morning he
seemed confused. He had a temperature of 99.1 that increased to
100.3 even on Tylenol. He reported to the nurses that he had a
cough, though the nurses didn't see him coughing before they
transferred him. He was weak and had decreased breath sounds on
exam there.
In the ED, initial VS were: 98.5 77 118/76 18 98% RA
Labs showed:
-WBC 10.8 HGB 12.3/HCT 38.4 PLT 125
-Glucose 93 BUN 23 Cr 0.8 Na 141 K 4.1
-INR 1.5
-UA: Neg Nitrite, Neg Leuks, Few Bacteria 11 RBC's
CT Head showed:
No acute intracranial process. There was a new but chronic left
basal ganglia lacunar infarct since ___.
Chest Xray showed:
Low lung volumes with patchy bibasilar airspace
opacities,potentially
atelectasis, but infection or aspiration could not be excluded.
Received:
IV Vancomycin 1000 mg
IV CefePIME 2 g
IVF 1000 mL NS
Transfer VS were 98.5 80 142/95 16 97% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient is unable to provide history.
He is awake and alert and responds hello and okay to questions
though he cannot understand.
Past Medical History:
Dr. ___ is his PCP
- ___
- ___ disease, diagnosed in ___, with DBS in place
(unclear when it was placed)
- constipation
- cough
- HTN
- insomnia
- low back pain
- sleep disturbance
Social History:
___
Family History:
unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 98.2, 135/94, 83, 18, 99% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD, deep brain
stimulator in place below the skin on b/l upper chest with cords
leading up neck under skin.
CARDIAC: irregularly irregular rate and rhythm, S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, seems mildly tender to epigastric
area unclear as patient speaks ___ and confused, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS - 98.2 150/99 59 18 96RA
GENERAL: NAD, A+O ___, very mobile.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD, deep brain
stimulator in place below the skin on b/l upper chest with cords
leading up neck under skin.
CARDIAC: irregularly irregular rate and rhythm, S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:38AM BLOOD ___
___ Plt ___
___ 10:38AM BLOOD ___
___ Im ___
___
___ 10:38AM BLOOD ___ ___
___ 10:38AM BLOOD ___
___
___ 10:50AM BLOOD ___
___ Base ___
___ 10:50AM BLOOD ___
___ 10:50AM BLOOD O2 ___
DISCHARGE LABS:
===============
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD ___
___ 06:16AM BLOOD ___
___ 05:40AM BLOOD ___
MICROBIOLOGY:
=============
-Blood cx x2: negative
-urine cx: negative
IMAGING:
========
NCHCT: 1. No acute intracranial process.
2. Interval development of a chronic lacunar infarct in the left
basal
ganglia, new since ___.
3. Stable appearance of known right middle cerebral artery
aneurysm, better
assessed on prior CTA from ___.
4. DBS electrode placements are unchanged.
5. Unchanged 5 mm right ___ partly calcified mass,
likely a
meningioma.
CXR: Low lung volumes with patchy bibasilar airspace opacities,
potentially
atelectasis, but infection or aspiration cannot be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amantadine 200 mg PO QPM
2. ___ 2.5 TAB PO 5X/DAY
3. Neupro (rotigotine) 8 mg/24 hour transdermal q24h
4. Atorvastatin 10 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Guaifenesin 10 mL PO Q4H:PRN cough
9. Artificial Tears 1 DROP BOTH EYES QID:PRN dryness
10. Milk of Magnesia 30 mL PO PRN CONSTIPATION
11. Bisacodyl 10 mg PR QHS:PRN CONSTIPATION
12. Magnesium Citrate 300 mL PO PRN CONSTIPATED
13. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Fentanyl Patch 12 mcg/h TD Q72H
16. Sertraline 200 mg PO DAILY
17. Furosemide 10 mg PO DAILY
18. rivastigmine tartrate 4.5 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amantadine 200 mg PO QPM
3. Artificial Tears 1 DROP BOTH EYES QID:PRN dryness
4. Atorvastatin 10 mg PO DAILY
5. Bisacodyl 10 mg PR QHS:PRN CONSTIPATION
6. ___ 2.5 TAB PO 5X/DAY
7. Furosemide 10 mg PO DAILY
8. Guaifenesin 10 mL PO Q4H:PRN cough
9. Milk of Magnesia 30 mL PO PRN CONSTIPATION
10. Neupro (rotigotine) 8 mg/24 hour transdermal q24h
11. rivastigmine tartrate 4.5 mg oral BID
12. Sertraline 200 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY
16. Fentanyl Patch 12 mcg/h TD Q72H
17. Magnesium Citrate 300 mL PO PRN CONSTIPATED
18. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
19. CefePIME 2 g IV Q12H Duration: 2 Days
RX *cefepime [Maxipime] 2 gram 1 vial iv every 12 hours Disp #*5
Vial Refills:*0
20. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Health Care Associated Pneumonia
Toxic Metabolic Encephalopathy
Secondary Diagnosis:
Chronic lacunar stroke
Atrial fibrillation
___ disease
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 (AP AND LAT)
INDICATION: History: ___ with fever, altered mental status
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ chest radiograph
FINDINGS:
Lung volumes are low which accentuate the size of the cardiac silhouette which
remains moderately enlarged. Mediastinal contour is similar. Crowding of
bronchovascular structures is demonstrated without overt pulmonary edema.
Patchy bibasilar airspace opacities may reflect atelectasis in the setting of
low lung volumes. No pneumothorax or pleural effusion is identified. There
are no acute osseous abnormalities. Electronic devices project over the
anterior aspects of the chest bilaterally with leads coursing cephalad into
the neck compatible with deep brain stimulator devices.
IMPRESSION:
Low lung volumes with patchy bibasilar airspace opacities, potentially
atelectasis, but infection or aspiration cannot be excluded.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with altered mental status
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.5 cm;
CTDIvol = 48.8 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
mGy-cm
COMPARISON: CT head without contrast from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominence of ventricles and sulci are compatible with age
related global atrophy. Ill-defined periventricular and subcortical white
matter hypodensities are nonspecific but likely due to the sequela of chronic
small vessel ischemic changes. There has been interval development of chronic
lacunar infarct in the left basal ganglia, new since ___.
The imaged paranasal sinuses are clear. Mastoid air cells and middle ear
cavities are well aerated. The bony calvarium is intact. A partly calcified
right extra-axial 5 mm dural based lesion adjacent to the right lobe is
unchanged since ___, likely a meningioma. There is stable appearance of the
known 6 mm right middle cerebral artery aneurysm, better assessed on prior CTA
from ___. The bilateral DBS electrodes are unchanged in appearance and
location.
IMPRESSION:
1. No acute intracranial process.
2. Interval development of a chronic lacunar infarct in the left basal
ganglia, new since ___.
3. Stable appearance of known right middle cerebral artery aneurysm, better
assessed on prior CTA from ___.
4. DBS electrode placements are unchanged.
5. Unchanged 5 mm right extra-axial partly calcified mass, likely a
meningioma.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified, Pneumonia, unspecified organism
temperature: 98.5
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 118.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | ___ year old gentleman with history of CVA, ___ with deep
brain stimulator and Dementia, who presented from nursing home
with fever and altered mental status and cough, concerning for
pneumonia.
#Toxic/metabolic encephalopathy
#Dementia with behavioral disturbances
Has fevers and bibasilar opacities on chest xray concerning for
pneumonia and leukocytosis. No hypoglycemia, hyponatremia or
hypernatremia. No signs to suggest meningitis. Blood Cx and UCx
negative, sputum contaminated. No intracranial hemorrhage or
other acute process on CT head, but with evidence of chronic
lacunar infarct; per neurology, unlikely to be the underlying
etiology of his confusion. Likely toxic metabolic encephalopathy
due to infection. Started on vanc/cefepime for HCAP,
subsequently transitioned to cefepime alone. Confusion improved
with treatment of PNA but he has baseline dementia with
behavioral disturbances. Had some hospital related delirium
which improved with Seroquel and delirium precautions, and
appears to be at baseline by discharge. Electrolytes were within
normal limits, and he didn't have any focal neurological
deficits.
#Pneumonia: Patient with fevers, leukocytosis and bibasilar
opacities on presentation. Resides in a nursing home, so would
be healthcare associated pneumonia. Induced sputum with
contaminated sample. Urine legionella negative. Started on
vanc/cefepime ___, dc'd ___ ___ given no suspicion for staph
PNA. Symptoms improved with treatment. Started Cefepime 2G IV
q12hr for 8 day course (d8 ___ treated with IV abx for
whole course since allergic to levaquin.
#Subacute stroke: NCHCT showed new stroke from ___ when he was
admitted for L MCA stroke. Neurology was consulted who said it
was unconcerning, and recommended ongoing optimization of risk
for recurrent stroke with anticoagulation, lipid management, and
blood pressure management. Patient used to be on rivaroxaban but
it had been d/c'ed prior, reportedly due to concern for falls.
He was not on aspirin or any other blood thinner prior to
admission. He was started on apixiban during this admission, and
should continue to receive anticoagulation moving forward given
his high stroke risk. Risk and benefit of anticoagulation was
discussed in great detail with his daughter/healthcare proxy
# ___ disease:
- Continued on Amantadine, ___, rivastigmine
#Depression:
- Continued on sertraline 200 mg daily
#BPH:
- continued on tamsulosin
TRANSITIONAL ISSUES
===================
-Continue CefePIME 2 g IV Q12H through ___.
-If blood pressure becomes consistently elevated above ___
systolic, consider initiation of antihypertensive medications.
-Continue delirium precautions
CODE: Full Code
EMERGENCY CONTACT HCP: wife, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 01:30PM BLOOD WBC-2.4* RBC-3.11* Hgb-9.5* Hct-30.1*
MCV-97 MCH-30.5 MCHC-31.6* RDW-15.8* RDWSD-55.9* Plt Ct-82*
___ 01:30PM BLOOD Neuts-29.5* ___ Monos-23.4*
Eos-4.5 Baso-0.4 AbsNeut-0.72* AbsLymp-1.03* AbsMono-0.57
AbsEos-0.11 AbsBaso-0.01
___ 12:14PM BLOOD ___ PTT-28.3 ___
___ 10:25AM BLOOD Glucose-84 UreaN-28* Creat-4.5* Na-130*
K-5.2 Cl-91* HCO3-27 AnGap-12
___ 10:25AM BLOOD ALT-19 AST-73* LD(___)-515* CK(CPK)-53
AlkPhos-141* TotBili-0.5
___ 10:25AM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.9 Mg-2.1
___ 10:32AM BLOOD Lactate-1.4
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-2.4* RBC-2.89* Hgb-8.9* Hct-27.8*
MCV-96 MCH-30.8 MCHC-32.0 RDW-15.6* RDWSD-55.3* Plt Ct-80*
___ 07:00AM BLOOD ___ PTT-32.4 ___
___ 07:00AM BLOOD Glucose-88 UreaN-24* Creat-4.7* Na-134*
K-4.3 Cl-95* HCO3-27 AnGap-12
___ 07:00AM BLOOD ALT-20 AST-39 AlkPhos-144* TotBili-0.5
___ 07:00AM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.2 Mg-2.0
IMAGING:
========
RUQUS
1. Cirrhosis with trace ascites and splenomegaly.
2. Patent main, right, left portal vein branches with
appropriate direction of flow.
3. Thickened gallbladder likely due to liver disease without
evidence of acute cholecystitis or stones.
CULTURE:
========
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
IDENTIFICATION AND Susceptibility testing requested per
___
___ (___) (___). FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
VANCOMYCIN------------ 1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Fexofenadine 90 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 300 mcg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Omeprazole 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
8. rifAXIMin 550 mg PO BID
9. Sarna Lotion 1 Appl TP QID:PRN itchy
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Simethicone 40-80 mg PO QID:PRN abd pain
13. Thiamine 100 mg PO DAILY
14. Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
15. HydrOXYzine 25 mg PO Q8H:PRN pruritis
16. TraZODone 50 mg PO QHS:PRN insomnia
17. Virt-Caps (B complex with C 20-folic acid) 1 mg oral DAILY
18. biotin 5 mg oral DAILY
19. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
3. biotin 5 mg oral DAILY
4. Fexofenadine 90 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. HydrOXYzine 25 mg PO Q8H:PRN pruritis
7. Levothyroxine Sodium 300 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Nepro Carb Steady (nut.___.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID
10. Omeprazole 20 mg PO DAILY
11. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
12. rifAXIMin 550 mg PO BID
13. Sarna Lotion 1 Appl TP QID:PRN itchy
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Simethicone 40-80 mg PO QID:PRN abd pain
17. Thiamine 100 mg PO DAILY
18. TraZODone 50 mg PO QHS:PRN insomnia
19. Virt-Caps (B complex with C 20-folic acid) 1 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bacteremia
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 ___ year old male with chief complaint of positive blood
cultures. pt has ETOH/NASH cirrhosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Prior right upper quadrant ultrasound performed on ___ and prior CT of the abdomen pelvis dated ___
FINDINGS:
LIVER: The liver is diffusely heterogeneous and echogenic. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass.
The main portal vein patent with hepatopetal flow. The right and left portal
branches demonstrate appropriate direction of flow with appropriate waveforms.
There is trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: There is no evidence of stones. Gallbladder wall thickening is
likely due to chronic liver disease. The gallbladder is not distended.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 21.4, previously 20.6 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 7.6 cm
Left kidney: 10.4 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhosis with trace ascites and splenomegaly.
2. Patent main, right, left portal vein branches with appropriate direction of
flow.
3. Thickened gallbladder likely due to liver disease without evidence of acute
cholecystitis or stones.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Positive blood cultures
Diagnosed with Bacteremia
temperature: 96.3
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 128.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a pmhx of COPD,
hypothyroidism, ESRD ___ PSGN on HD, recently diagnosed
NASH/EtOH cirrhosis c/b GAVE, hx EV not seen on most recent EGD
___, recent hx native aortic valve endocarditis ___
enterococcus & staph epi felt to be iatrogenic from CVC catheter
(s/p 6wk
dapto/gent finished ___ who presents after ___ outpatient
blood cx grew GPCs.
ACTIVE ISSUES
=============
# CoNS bacteremia
Recent history of native aortic valve endocarditis ___
enterococcus & staph epi felt to be iatrogenic from CVC catheter
(s/p 6wk dapto/gent finished ___. Repeat TTE on ___ showed
resolution of vegetation. However, admitted with complaint of
chills and ___ blood cultures ___ growing GPCs in clusters.
Ultimately only ___ bottles (anaerobic), subsequent
pre-antibiotic cultures (including at ___ are
negative. Given asymptomatic, subsequent culture data we feel at
this time it is contaminant. He was given explicit return to
hospital conditions including fever, ns, chills, general
malaise, fatigue etc.
# Pancytopenia
# Acute on chronic anemia
# Thrombocytopenia
# Neutropenia
Presenting with acute on chronic anemia (baseline hemoglobin
___. Underlying anemia likely secondary to chronic disease.
Thrombocytopenia likely secondary to known cirrhosis and
platelets are close to baseline. No active signs of bleeding on
exam. Also has known neutropenia. Seen by hem/onc in ___ who
thought likely chronic component from chronic disease (cirrhosis
and ESRD).
# EtOH cirrhosis
EtOh / NASH cirrhosis complicated by HE and EV and GAVE.
MELD 28, Childs C on admission.
VOLUME: Euvolemic. Trace ascites on RUQUS, unsafe to tap. Portal
vein is patent.
BLEED: Known GAVE, history of EV but not seen on most recent EGD
- omeprazole 20mg daily
HE: Hx of HE
- continue Lactulose/rifaximin
INFXN: no history of SBP
- GPC treatment as above
NUTRITION: c/s nutrition
- Thiamine/folate
# ESRD on HD ___
Dialysis while inpatient according to schedule.
#Pruritus
#Contact dermatitis of dialysis catheter site
Patient with diffuse itch that has been ongoing, developing
during the last hospitilization. Has been following with
dermatology as an outpatient. Was on Dupixent but discontinued
given was not helping. Treated with topical aug. betamethasone
ointment prn |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
falls, confusion
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
PCP:
Name: ___
___: ___
Phone: ___
Fax: ___
___ with DM2, HTN, who presents with confusion after recent
falls. Patient was recently seen in the ED at an OSH for R knee
pain. He was found to be hyperglycemic as well. He was given
meftormin and vicodin and discharged. Since then his cousin as
noted increased confusion. He has had confusion over his
medications. He has also fallen x2, unwitnessed, with FSBG in
the 350s. The patient states that he has chronic R knee pain,
worse over the last few days, no trauma. This has led to
weakness and falls, without LOC, palps, HA, or focal
weakness/numbness. He also complains of lower back pain,
fatigue, and feeling of tongue weakness and mild confusion.
This has happened over the last few days, not acutely, waxes and
wanes, and is persistent. He otherwise denies HA, F/C, CP, SOB,
n/v/d, constipation, dysuria, rash, joint swelling. Of note, he
has not taken his medications in > 6 mo due to laziness.
In the ED, AVSS. Extensive medical work up performed.
Hospitalized for further work up given risk of complications
Review of systems: 10 point review of systems negative except as
listed above
Past Medical History:
DM2
HTN
Glaucoma
? Arthritis
Social History:
___
Family History:
No history of CVD, stroke, DM, cancers
Physical Exam:
Physical Exam on Admission:
VS: T 95.3, BP 135/84, HR 79, RR 18, 100%RA
Gen: well appearing, tired, NAD
HEENT: EOMI, PERRL, anicteric sclera, MM dry, OP clear
Neck: supple no LAD, no bruits
Heart: RRR no MRG
Lung: CTAB no wheezes or crackles
Abd: soft NT/ND +BS no rebound or guarding
Ext: warm well perfused, trace bilat edema. R knee without
effusion or erythema. Full ROM without pain, no bony
deformities
Skin: no bruising or rash
Neuro: CN II-XII intact. srength ___ in upper/lower ext muscle
groups bilat. No asterixis. Normal FNF. AOx3, can give days
of week forwards and backwards
Physical Exam on Transfer to Neurology:
Vital signs:
T: 96.6 Tmax 97.4
P/HR: 60-70
BP: 140-160/ 50-60
RR: ___
General: Awake, cooperative, NAD.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Supple, with full range of motion and no nuchal rigidity.
No carotid bruits. No lymphadenopathy.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing.
Cardiac: RRR, normal S1/S2, no M/R/G.
Abdomen: Soft, non-tender, and non-distended, + normoactive
bowel
sounds.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Oriented to person, ___ ___. Pt
has difficulty recalling some earlier history, but knows that he
is in the hospital because he has trouble walking and memory
problems. Attentive, and able to name ___ backward without
difficulty. Speech was not dysarthric. Language is fluent with
intact repetition and comprehension, normal prosody, and normal
affect. There were no paraphasic errors. Able to read and write
without difficulty. Naming is intact to both high and low
frequency objects. Able to follow both midline and appendicular
commands. Memory - cannot register more than 3 objects at once
(only remember "red and ___ but not the other 3 items).
Good knowledge of recent and current events ___ - tsunami"
"___ - earthquake". Calculation was intact (answers seven
quarters in $1.75). Digit span forward good with ___, start to
make mistake at 6 numbers at once. digit span backward error at
4
digis. There was no evidence of apraxia or neglect or ideomotor
apraxia; the patient was able to reproduce and recognize
hammering a nail and brushing teeth with both hands. There was
no
evidence of left-right confusion as the patient was able to
accurately follow the instruction to tough left ear with right
hand.
On word-generation testing, the patient was able to name 14
words
that begin with "F".
Clockface - draws a circular clock, but unable to fill in the
numbers correctly, (wrote "1" at where "12" is, then "2" at
where
"6" is, he wrote in two "9"s at the correct position, there is
no
hands)
unable to do trails a
Frontal release signs are: Not present, including specifically
rooting, glabellar, grasp, and palmar-mental reflex.
-Cranial Nerves:
II: R eye constant dilated at 4mm, does not react to light. L
eye
is pupil round, reactive to light, 3 to 2mm and brisk. Visual
fields are full.
III, IV, VI: EOMs full and conjugate; no nystagmus. No saccadic
intrusion during smooth pursuits. Normal saccades.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Brow elevation is
symmetric. Eye closure is strong and symmetric.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
No drift. No asterixis. No tremor or fasciculations were
observed. Normal muscle bulk and tone; no flaccidity,
hypertonicity, or spasticity noted.
Delt Bic Tri WE FF FE IO | IP Q Ham TA ___
L ___ ___ 5 5 5 5 5 5 5
R ___ ___ 5 5 5 5 5 5 5
-Sensory:
No gross deficits to light touch, pinprick, cold sensation, or
vibratory sensation in either distal lower extremity. Joint
position sense is normal in both lower extremities (great toes).
Eyes-closed Finger-to-nose testing revealed no proprioceptive
deficit (did not miss nose).
-Reflexes (left; right):
Pec/delt (++;++)
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
___ / achilles (++;++)
Plantar response was flexor bilaterally.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia noted on
rapid-alternating movements.
-Gait:
takes wide based, small steps, wobbly. positive romberg.
Physical Exam on Discharge:
Pertinent Results:
Admission Labs:
137 / ___
3.9 / 24 / 1.1
ALT: 10 AP: 79 Tbili: 0.5 Alb: 4.3
AST: 15 LDH: Dbili: TProt:
___: Lip:
88
6.9 \ 14.6/ 209
/ 41.0 \
N:76.5 L:16.5 M:4.6 E:1.4 Bas:1.0
UA: unremarkable. Gluc 150.
HIV negative
___, ma, ta, Thyroid US
EEG negative
[x] CSF cytology/flow cytometry negative
[x] ID following - rec continuing acyclovir empirically for 21
days unless have a second negative PCR
[x] Other labs negative: electrolytes, LFT's, TSH, B12,
homocysteine, ESR/CRP, ___, Lyme, RPR, TPO, ___
Microbiology:
Urine cx no growth
Blood cx no growth
Neg Lyme Ab in serum
CSF: Gram stain negative and no polys.
CSF VDRL, cryptococcal antigen, enterovirus, cytology with flow
cytometry negative
CSF lymphocytic choriomeningitis virus ***
CSF HSV PCR negative
Repeat CSF HSV PCR ***
Imaging:
___ CT Head:
IMPRESSION: No evidence of acute intracranial process
___ CXR: IMPRESSION: No acute cardiopulmonary process.
___ L-spine: IMPRESSION:
Degenerative changes, including discogenic and facet
degenerative changes in the lower lumbar spine. No fracture
detected.
___ RIGHT KNEE, THREE VIEWS.
There are mild degenerative changes. Trace fluid in the
suprapatellar recess. No fracture is identified. Scattered
vascular calcification present.
Head MRI ___: IMPRESSION:
1. No evidence of acute infarction.
2. Mild scattered increased T2 and FLAIR hyperintensities in the
periventricular and subcortical white matter consistent with
chronic small
vessel ischemic disease.
Discharge/Notable Labs:
CSF studies:
TP 104 Glucose 82
46 WBC 1 RBC; 0N92L8M
45 WBC 0 RBC; 99L1E
.
A1c 11.2
TSH 1.6
B12 406
RPR negative
MMA pending
ESR CRP wnl
___ pending
homocysteine pending
Studies pending on transfer:
Official report of CSF cytology and flow cytoemetry (prelim
report is a polyclonal population of lymphocytes)
Radiology Report
INDICATION: ___ man with subacute decline in mental status, question
subacute stroke versus NPH versus other neurodegenerative stroke.
COMPARISON: CT head on ___.
TECHNIQUE: MR of head with and without contrast.
FINDINGS: The patient is post right parietal/frontal craniotomy. There are
no diffusion abnormalities. There is no evidence of hemorrhage, edema, mass,
mass effect or acute infarction. There are scattered periventricular white
matter T2 and FLAIR hyperintensities consistent with chronic small vessel
ischemic disease. Ventricles and sulci are normal in size and configuration.
There are no areas of abnormal enhancement. The visualized paranasal sinuses
and mastoid air cells are well aerated.
IMPRESSION:
1. No evidence of acute infarction.
2. Mild scattered increased T2 and FLAIR hyperintensities in the
periventricular and subcortical white matter consistent with chronic small
vessel ischemic disease.
Radiology Report
INDICATION: Rapid cognitive decline with encephalopathy of unknown etiology,
possibly paraneoplastic encephalitis. Evaluate for malignancy.
TECHNIQUE: MDCT axial images were acquired from the thoracic inlet through
the lesser trochanters following administration of both oral and intravenous
contrast material. Multiplanar reformations were performed.
COMPARISON: Chest radiographs from ___.
CHEST CT: Aside from minimal dependent atelectasis, the lungs are clear. No
pulmonary nodules are identified. The airways are patent to the subsegmental
levels bilaterally. There are no pleural effusions.
A 1.5 cm hypodense nodule is seen within the left lobe of the thyroid (2:8).
The thyroid gland is otherwise unremarkable. There are no pathologically
enlarged mediastinal, hilar, or axillary lymph nodes. Calcifications are seen
throughout the thoracic aorta, which is otherwise grossly unremarkable. Note
is made of a pseudobovine aortic arch with a common takeoff of the
brachiocephalic and left common carotid arteries (2:16). The heart is grossly
unremarkable. There is no pericardial effusion. The mid to lower esophagus
is slightly patulous, without evidence of wall thickening. Note is made of
coronary artery calcifications.
ABDOMEN CT: A tiny 2-mm hypodensity is seen within the left hepatic lobe
(2:44), too small to characterize but statistically a hamartoma or simple
cyst. An additional 6-mm hypodensity within the posterior right hepatic lobe
(2:58) is also too small to characterize. There is no intrahepatic biliary
duct dilatation. The portal vein is patent. The gallbladder, spleen,
pancreas, and adrenal glands are normal. There are several simple cysts
throughout both kidneys measuring up to 5.0 cm on the left and 2.8 cm on the
right. Additional tiny bilateral renal hypodensities are too small to
characterize but are also statistically simple cysts. The kidneys are
otherwise grossly unremarkable with symmetric excretion of contrast material.
The stomach and small bowel are grossly normal. There is extensive colonic
diverticulosis without evidence of diverticulitis. The appendix is normal.
There is no free fluid or free air in the abdomen. No pathologically enlarged
abdominal lymph nodes are seen. The abdominal aorta is normal in caliber and
its main branches are patent. Scattered aortic calcifications are seen.
PELVIS CT: The bladder is unremarkable. The prostate gland is grossly
unremarkable. There are no pathologically enlarged lymph nodes in the pelvis.
No free fluid is seen in the pelvis.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
Multilevel degenerative changes of the thoracolumbar spine are seen.
IMPRESSION:
1. No evidence of malignancy in the chest, abdomen, or pelvis.
2. 1.5 cm nodule in the left lobe of the thyroid could be further evaluated
with non-emergent ultrasound.
3. Bilateral simple renal cysts with additional tiny bilateral renal
hypodensities that are too small to characterize, but also likely represent
simple cysts.
4. Tiny hepatic hypodensities, too small to characterize, are statistically
hamartomas or simple cysts.
5. Coronary artery calcifications.
Radiology Report
INDICATION: Thyroid nodule seen on recent CT scan.
COMPARISONS: None.
FINDINGS: There is a hypoechoic 1.7 x 1.5 x 1.3 nodule in the left lobe of
the thyroid. There is no hypervascularity. Given the size and features, this
would meet criteria for fine-needle aspiration. Also in the left lobe are two
smaller nodules, both of which are hypoechoic. The first measures 0.6 x 0.5 x
0.4 cm. The second measures 0.7 x 0.6 x 0.4 cm. There is no hypervascularity
to these nodules. These can be monitored in followup.
The left lobe of the thyroid measures 4.5 x 2.6 x 2.3 cm. The right lobe of
the thyroid measures 4.4 x 2.6 x 2.3 cm. There are no nodules within the
right lobe of the thyroid. There are no enlarged adjacent lymph nodes.
IMPRESSION:
1. Large hypoechoic nodule in the mid left lobe of the thyroid meets criteria
for further evaluation with fine-needle aspiration.
2. Two smaller nodules in the left lobe of the thyroid are of unclear
significance and should it be followed expectantly for change in size.
Results were discussed with Dr ___.
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ male with new onset of confusion.
FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear.
The costophrenic angles are sharp where seen. However, the right posterior
costophrenic angle is not included in the field of view. The
cardiomediastinal silhouette is within normal limits. Osseous and soft tissue
structures are notable for degenerative changes of the right acromioclavicular
joint and hypertrophic changes in the spine.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ male with new onset of confusion. Evaluate for acute
intracranial process.
COMPARISONS: None available.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted images in coronal and
sagittal axis were generated.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. Periventricular white matter changes suggest chronic small vessel
ischemic disease. The lateral ventricles and sulci are prominent, likely from
age-related involutional changes. The basal cisterns appear patent and there
is preservation of gray-white matter differentiation.
There is a prior right parietofrontal craniotomy. The paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Vascular calcifications
are noted more prominent at the carotid siphons. Pannus is present at the
foramen magnum. Replaced ocular lenses.
IMPRESSION: No evidence of acute intracranial process.
Radiology Report
HISTORY: Right knee pain, rule out fracture or dislocation.
RIGHT KNEE, THREE VIEWS.
There are mild degenerative changes. Trace fluid in the suprapatellar recess.
No fracture is identified. Scattered vascular calcification present.
Radiology Report
HISTORY: Back pain.
L-SPINE (AP & LAT)
There are five non-rib-bearing vertebral bodies. Vertebral body heights are
preserved. There are moderate-to-moderately severe discogenic changes, with
disc space narrowing and marginal osteophytes at multiple levels. Disc space
narrowing worst at L4/5 posteriorly and at L5/S1. There is severe facet
arthrosis, worse from L4 through S1. No spondylolisthesis is identified.
Faint vascular calcification present.
IMPRESSION:
Degenerative changes, including discogenic and facet degenerative changes in
the lower lumbar spine. No fracture detected.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: FREQUENT FALLS
Diagnosed with ALTERED MENTAL STATUS , DIABETES UNCOMPL ADULT, JOINT PAIN-L/LEG
temperature: 96.6
heartrate: 90.0
resprate: 16.0
o2sat: 97.0
sbp: 156.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ with type 2 diabetes mellitus, hypertension, history of
subarachnoid hemorrhage ___ years ago s/p evacuation recently
started on vicodin for R knee and back pain admitted for
confusion.
#NEURO:
Patient was admitted with confusion and waxing and waning
cognitive impairment. He was ruled out for UTI and pneumonia and
other usual infections. TSH, B12, rpr were all wnl. Imaging with
Head CT and Brain MRI was negative except for chronic
microvascular disease. Kumbar puncture was notable for
lymphocytic pleocytosis, elevated total protein, and normal
glucose. The patient was seen by Neurology, Geriatrics, and
Infectious Disease. CSF gram stain and culture were negative, as
well as VDRL, HSV PCR, cytology with flow cytometry. Patient was
initially started on Vancomycin/CTX/Ampicillin and Acyclovir,
but Vancomycin/CTX/Ampicillin were quickly discontinued based on
lymphocytic predominance and subacute decline more consistent
with a viral process. Given high suspicion for seizures patient
was transferred to Neurology for 24 hour EEG monitoring. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with L4 burst fracture. On ___, patient bent
forward to pick up adult daughter with special needs, felt acute
onset lower back pain. Since then, pain
has been persistently severe, and now feels as though it is
associated with BLE weakness, as she found it difficult to
ambulate down stairs today. She required the assistance of EMS
to take her to ___ because of her weakness. At ___,
they performed an MR ___ which showed a burst fracture of L4
with posterior involvement compressing the cauda equina.
Patient
denies saddle anesthesia, loss of bowel or bladder function,
fevers.
Past Medical History:
History of PE/DVT in ___, on rivaroxaban
Early Alzheimer's dementia, on donepezil
Social History:
___
Family History:
N/C
Physical Exam:
T2-L1 (Trunk)
SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L decreased SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 4 5 5 5 5 5 5
Reflexes
Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)
R 1 1 1 1 1
L 1 1 1 1 1
___: Negative
Babinski: Downgoing
Clonus: No beats
Perianal sensation: Normal
Rectal tone: Intact
Pertinent Results:
___ 05:01PM GLUCOSE-103* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
___ 05:01PM estGFR-Using this
___ 05:01PM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 05:01PM WBC-7.5 RBC-4.47 HGB-12.8 HCT-40.4 MCV-90
MCH-28.6 MCHC-31.7* RDW-13.7 RDWSD-45.7
___ 05:01PM NEUTS-75.3* LYMPHS-15.9* MONOS-7.5 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-5.64 AbsLymp-1.19* AbsMono-0.56
AbsEos-0.04 AbsBaso-0.03
___ 05:01PM ___ PTT-23.0* ___
___ 05:01PM PLT COUNT-186
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QHS
2. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
Please hold 24 hours prior to ___ surgery
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6h Disp #*40 Tablet
Refills:*0
5. Senna 17.2 mg PO HS
6. Donepezil 10 mg PO QHS
7. HELD- Rivaroxaban 15 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until told by Dr. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
l4 burst fracture
lumbar stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent with assistance.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with lower extremity weakness w/ spinal injury//
Fracture? pneumonia?
TECHNIQUE: Supine AP upright portable view of the chest
COMPARISON: None.
FINDINGS:
Patient is rotated somewhat to the left. Given this, no focal consolidation
is seen. There is no large pleural effusion or pneumothorax. Cardiac
silhouette size is borderline to mildly enlarged. Mediastinal contours are
grossly unremarkable. There may be mild central pulmonary vascular
congestion. No obvious displaced fracture is seen, but if there is clinical
concern for such, cross-sectional imaging is more sensitive.
IMPRESSION:
Borderline to mild enlargement of the cardiac silhouette.
Possible mild central pulmonary vascular congestion.
No obvious intrathoracic displaced fracture, but if there is clinical concern
for such, cross-sectional imaging is more sensitive.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal MRI, Transfer
Diagnosed with Low back pain
temperature: 98.2
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 152.0
dbp: 76.0
level of pain: 8
level of acuity: 2.0 | Patient admitted on ___ for L4 burst fracture. Patient
evaluated by ___ who recommended rehab. patient tolerating
regular diet and oral pain medications. Will be discharged to
rehab |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Post-operative fever s/p right distal femur component exchange
and I&D on ___.
Major Surgical or Invasive Procedure:
N/A.
History of Present Illness:
___ y/o M with a history of right distal femur chondrosarcoma s/p
resection and prosthesis placement (___), complicated by
prosthesis infection s/p I&D ___, cultures grew MSSA,
ox-sensitive staph lugdenensis, diphtheroids, and mixed flora),
recent admission ___ for PJI, s/p prosthesis exchange ___,
discharged on Vanc/CTX/rifampin presenting ___ with new fevers
and R knee pain.
Patient reports that he had relatively minimal right knee pain
at discharge on ___. Over the course of the last few days,
however, pain in the right knee has increased (requiring more
frequent oxycodone), associated with low-grade fevers to ___ or
so. On ___ he spiked a fever to ___, and when ___ visited
on ___ he was reportedly febrile to 104.7F. Patient reports
scant discharge from the right knee but continues to be able to
bear weight. He reports strict adherence to his antibiotic
regimen (rifampin 300mg q12h, CTX 2g q24h, and vancomycin 1500mg
q8h) with sterile administration technique. He denies other
localizing infectious symptoms such as SOB, cough, abdominal
pain, N/V, diarrhea/constipation, dysuria/hematuria, or
pain/redness at the ___ site. Of note, OPAT labs on ___
showed CRP 91.7 and Vanco level of 10.2.
Given his high fever, ___ called EMS on ___ and patient was
transferred to ___, where he received CTX 2g and
Vancomycin 1250mg on ___ at 1500, as well as 2.6L IVFs. He
was transferred to ___ ED, where he was febrile to 101.7F with
HR 106, BP 117/63, RR 16, 97% RA. WBC 5.3, BMP WNL, UA negative.
Blood and urine cultures were drawn. He was given Tylenol 1g,
oxycodone 10mg, and rifampin 300mg. He was seen by general
orthopedics, who recommended WBAT and continuation of
antibiotics.
Past Medical History:
Tobacco use, GERD, chondrosarcoma right distal femur.
Social History:
___
Family History:
Denies family history of cancer.
Physical Exam:
General: Sitting upright in bed in NAD, awake and alert and
oriented, answering questions appropriately. Pleasant affect.
Right lower extremity:
Mild serosanguinous discharge from mid-incision.
Sutures intact. No erythema.
Sensation intact to light touch in femoral, LFC, saphenous,
sural, SP, DP, T distributions. Hip flexion intact but weak
secondary to pain. Knee flexion/extension intact. Able to extend
to ~15 degrees short of 0 (limited by pain). Motor intact to
ankle plantarflexion/dorsiflexion, ___. Skin warm and
well-perfused.
Pertinent Results:
___ 05:26AM GLUCOSE-105* UREA N-10 CREAT-0.6 SODIUM-136
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
___ 05:26AM CALCIUM-8.2* PHOSPHATE-3.6 MAGNESIUM-1.9
___ 05:26AM CRP-57.5*
___ 05:26AM VANCO-6.1*
___ 05:26AM WBC-4.6 RBC-3.58* HGB-9.5* HCT-29.9* MCV-84
MCH-26.5 MCHC-31.8* RDW-13.9 RDWSD-42.5
___ 05:26AM PLT COUNT-285
___ 08:46PM ___ PTT-37.6* ___
___ 08:15PM LACTATE-0.9
___ 07:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Medications on Admission:
Medications - Prescription
DIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth every
eight
(8) hours as needed for muscle spasm
ENOXAPARIN - enoxaparin 40 mg/0.4 mL subcutaneous syringe. ___aily for at least 4 weeks - (Prescribed
by
Other Provider)
HYDROMORPHONE [DILAUDID] - Dilaudid 2 mg tablet. 1 tablet(s) by
mouth every four (4) hours as needed for pain do not combine
with
oxycodone
OXYCODONE - oxycodone 5 mg tablet. 1 to 2 tablet(s) by mouth
every six (6) hours as needed for pain
VANCOMYCIN IN 0.9 % SODIUM CHL - vancomycin 1.5 gram/250 mL in
0.9 % sodium chloride intravenous. 1500 mg iv every eight (8)
hours
Medications - OTC
ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - Acetaminophen
Extra Strength 500 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)
DIPHENHYDRAMINE-ACETAMINOPHEN [ACETAMINOPHEN ___ - Acetaminophen
___ 25 mg-500 mg tablet. 2 (Two) tablet(s) by mouth at bedtime -
(Prescribed by Other Provider; Dose adjustment - no new Rx)
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - Prilosec OTC 20 mg
tablet,delayed release. ___ tablet(s) by mouth daily - (OTC)
POLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram/dose oral
powder. one powder(s) by mouth daily as needed for constipation
-
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Daptomycin 500 mg IV Q24H Prosthetic Joint Infection
Duration: 6 Weeks
RX *daptomycin 500 mg 500 mg IV q 24 hr Disp #*42 Vial
Refills:*0
3. Docusate Sodium 100 mg PO BID
While taking narcotic pain medications.
4. Senna 8.6 mg PO BID
While taking narcotic pain medications.
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hr Disp #*30
Tablet Refills:*0
7. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV q 24
hours Disp #*42 Intravenous Bag Refills:*0
8. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
9. Omeprazole 20 mg PO DAILY
10. Rifampin 300 mg PO Q12H
RX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*84
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Post-operative fever
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ y/o M with a history of R distal femur chondrosarcoma s/p
resection and prosthesis placement (___), complicated by prosthesis
infection s/p I D ___, cultures grew MSSA, ox-sensitive staph
lugdenensis, diphtheroids, and mixed flora), recent admission ___ for PJI,
s/p prosthesis exchange ___, discharged on Vanc/CTX/rifampin presenting ___
with new fevers and R knee pain. Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
Superior and anteromedial to the right popliteal fossa there is a 4.1 x 2.7 x
4.6 cm complex fluid collection that appears to extend inferiorly into the
right popliteal fossa, in the area of patient's prior surgery.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 4.6 cm complex fluid collection in the area of patient's recent surgery.
Radiology Report
INDICATION: ___ y/o M with a history of R distal femur chondrosarcoma s/p
resection and prosthesis placement (___), complicated by prosthesis
infection s/p I D ___, cultures grew MSSA,ox-sensitive staph lugdenensis,
diphtheroids, and mixed flora),recent admission ___ for PJI, s/p
prosthesis exchange ___ on Vanc/CTX/rifampin presenting ___ with
new fevers and R knee pain.// Please evaluate for abscess and other evidence
of infection R knee
TECHNIQUE: Multidetector CT imaging was performed of the right lower
extremity after the administration of intravenous contrast. Multiplanar
reformatted images are provided.
DOSE: Total DLP (Body) = 1,052 mGy-cm.
COMPARISON: Radiographs of the right femur dated ___
FINDINGS:
Patient is status post extended right femoral prosthesis secondary to de
differentiated chondrosarcoma resection. Streak artifact from hardware
slightly limits assessment of surrounding structures. There is no evidence of
hardware related complication. No fracture is identified.
An amorphous rim enhancing fluid collection is seen surrounding the
prosthesis, measuring up to approximately 6.7 x 5 x 15.2 cm (5:159, 16:45),
and extending into the adjacent soft tissues, particularly on the medial side
(5:177). Several of these collections contain foci of gas, which can be seen
in the setting of recent surgery.
IMPRESSION:
1. Status post extended right femoral prosthesis placement, with streak
artifact from hardware slightly limiting assessment of surrounding structures.
No evidence of hardware related complication.
2. An amorphous rim enhancing fluid collection is seen surrounding the
prosthesis and within the adjacent soft tissues. In the setting of recent
postoperative status, it is difficult to distinguish between postoperative
seroma and infection. Several of these collections contain foci of gas, which
can be seen in the setting of recent surgery. Clinical correlation and fluid
sampling is recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Fever, unspecified
temperature: 99.8
heartrate: 94.0
resprate: 14.0
o2sat: 98.0
sbp: 121.0
dbp: 69.0
level of pain: 9
level of acuity: 3.0 | ___ was admitted to the Hospital Medicine service on
___ from the ___ ED. A duplex ultrasound study of the
right lower extremity revealed no thrombosis but did reveal a
fluid collection consistent with post-operative seroma. The
Infectious Disease service was consulted by Hospital Medicine,
who recommended discontinuing Vancomycin given persistent low
trough levels as well as discontinuing Rifampin in favor of
Daptomycin and Ceftriaxone. A CT scan of the right lower
extremity was obtained at the request of Infectious Disease,
which was again notable for fluid collection consistent with
post-operative seroma. No evidence of hardware complication was
noted. Patient remained afebrile beginning on HD#1 and had no
complaints of constitutional symptoms such as fevers, chills,
nausea, or vomiting. He was mobilizing appropriately. Rifampin
was resumed, while continuing daptomycin and ceftriaxone at the
recommendation of Infectious Disease with the plan to complete a
6 week course in conjunction with close monitoring of his wound. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark urine/light stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of hypertension,
hypercholesterolemia and diabetes who presents to the ___
with fatigue x ___s dark urine/light stools since
___. The patient notes that his health began to decline when
he was switched from crestor to lipitor on ___ due to impending
formulary change of his insurance. He noticed fatigue after the
switch, and on ___ he noted decreased appetite and the
aforementioned colour changes in his stool and urine. Other
symptoms he has noted has included some generalized
musculoskeletal pain in his neck, back and left thigh. He also
has noted some chills since ___, but denies frank fevers. His
last dose of lipitor was the night before admission on ___.
Review of systems was negative for any recent abnormal food
exposures. No history of hepatitis or IV drug use. No belly
pain, nausea, vomiting, brbpr or melena. No dysuria or history
of kidney problems. No chest pain, cough or shortness of breath.
He does endorse fairly significant EtOH intake, generally ___
beers a day but as much as 6 drinks occasionally on weekends.
.
In the ED, initial VS: 99.4 84 127/62 18 100% ra. The patient
underwent a RUQ ultrasound that showed no extra or intrahepatic
duct dilation. The gallbladder was collapsed, although
gallbladder wall thickening was apparent. Labs were notable for
moderate elevation in aminotransferases, alkaline phosphatase
and mild conjugated hyperbilirubinemia. The patient also had
elevation in creatinine to 1.8, although baseline was unknown.
Past Medical History:
Hypertension
Hypercholesterolemia
Diabetes - diet controlled.
Erectile dysfunction
Alcohol abuse
Social History:
___
Family History:
FAMILY HISTORY: Father deceased ___ from colon ca. Mother
deceased from complications of diabetes. No siblings. Children
are healthy.
No family history of inflammatory bowel disease or liver
disease.
Physical Exam:
Admission VS - 100.4 129/75 91 18 98% on RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, mild scleral and oral icterus, MMM,
OP clear
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 non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, Palpable spleen tip and liver edge,
no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - grossly non focal.
Pertinent Results:
___ 03:28PM BLOOD WBC-6.3 RBC-4.00* Hgb-11.7* Hct-33.7*
MCV-84 MCH-29.3 MCHC-34.8 RDW-14.8 Plt ___
___ 04:45AM BLOOD WBC-5.8 RBC-3.60* Hgb-10.5* Hct-30.2*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.9 Plt ___
___ 03:28PM BLOOD Neuts-68.8 Lymphs-12.6* Monos-4.3
Eos-14.0* Baso-0.3
___ 03:28PM BLOOD ___ PTT-28.8 ___
___ 04:45AM BLOOD ___ PTT-28.5 ___
___ 03:28PM BLOOD Glucose-122* UreaN-26* Creat-1.8* Na-135
K-3.9 Cl-101 HCO3-22 AnGap-16
___ 04:45AM BLOOD Glucose-77 UreaN-21* Creat-1.4* Na-135
K-3.6 Cl-105 HCO3-20* AnGap-14
___ 03:28PM BLOOD ALT-139* AST-98* CK(CPK)-132 AlkPhos-306*
TotBili-2.7* DirBili-2.1* IndBili-0.6
___ 04:45AM BLOOD ALT-111* AST-91* CK(CPK)-140 AlkPhos-277*
TotBili-2.5*
___ 03:28PM BLOOD Lipase-38
___ 03:28PM BLOOD Albumin-4.1
PENDING Labs
___ 04:45AM BLOOD IgM HAV-PND
___ 04:45AM BLOOD AMA-PND Smooth-PND
___ 04:45AM BLOOD ___
___ 5:21 am URINE Source: ___.
URINE CULTURE (Pending):
Urine studies
___ 05:21AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:21AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:21AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:21AM URINE Mucous-RARE
___ 05:21AM URINE Hemosid-NEGATIVE
___ 05:21AM URINE Hours-RANDOM Creat-81 Na-81 K-11 Cl-83
Imaging
RUQ u/s: Contracted/collapsed gallbladder. apparent GB wall
thickening/edema may in part relate to contracted state vs true
edema. Neg sonographic ___. No intra-extra hepatic biliary
dilatation. patent portal vein. liver nl in echotexture.
Radiology Report
EXAM: Right upper quadrant ultrasound.
CLINICAL INFORMATION: ___ male with history of transaminitis and
elevated bilirubin.
COMPARISON: None.
FINDINGS: Liver demonstrates normal homogeneous echotexture, without focal
intrahepatic lesion seen. There is no evidence of intrahepatic biliary
dilatation. The main portal vein is patent. The common bile duct is normal
in caliber, measuring 0.3 cm in diameter. The gallbladder is
contracted/collapsed. Apparent gallbladder wall thickening/edema may relate
in part to contracted gallbladder state versus true gallbladder wall edema.
Sonographic ___ sign was absent. The pancreatic head was not well
assessed due to overlying bowel gas. No free fluid is seen in the right upper
quadrant. No evidence of hydronephrosis is seen in the right kidney.
IMPRESSION:
1. Contracted/collapsed gallbladder. Apparent wall thickening may relate in
part to the gallbladder's contracted state although gallbladder wall edema is
of concern. Negative sonographic ___ sign.
2. No evidence of intra- or extra-hepatic biliary dilatation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: DARK URINE/LIGHT STOOL
Diagnosed with OTHER MALAISE AND FATIGUE, ELEV TRANSAMINASE/LDH, JAUNDICE NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 99.4
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 62.0
level of pain: 2
level of acuity: 3.0 | ___ y.o man with history of HTN, HL, and DM present with
myalgias, low grade fever, mild organomegaly and cholestatic
liver enzymes concerning for DILI.
.
#Liver injury - Most likely dx given LFT pattern is cholestatic
drug-induced liver injury. Would also consider autoimmune
hepatitis type 1 given low grade temps and eosinophilia. Both of
the above can present very similarly. Low concern for alcohol
hepatitis or statin myopathy given nontypical lab patterns. Low
suspicion for cholecystitis given exam and other findings. Labs
for autoimmune hep was sent including ___, ama and antismooth
muscle antibodies and his anti-mitochondrial antibody returned
positive with a ratio of 1:160 at time of discharge. LFTs
downtrending at time of discharge. Plan to continue to hold
statin and cholestyramine at time of discharge with f/u with PCP
in few days for repeat labs. The patient's PCP was notified of
the positive AMA and will decide whether to refer the patient to
hepatology to evaluate for PBC versus type I autoimmune
hepatitis.
.
# Eosinophilia: Likely ___ hypersensitivity component of DILI vs
autoimmune hepatitis. Would also consider parasitic infection
given loose stool although lower likelihood given lack of
travel. Ordered stool o/p which are pending at time of
discharge.
.
# Low grade fever - Less likely to be infectious or
cholecystitis esp given benign exam. Can see low grade/fever
with DILI and autoimmune hepatitis. Did not spike fever during
hospitalization. Urine culture was checked for low grade temp
and XXX at time of discharge.
.
#Acute kidney injury - Admission creatinine 1.8 now improving.
Fena 1% and appears to be improving w IVF. Baseline appears to
be ~1.3 per Atrius records. Home ACE and diuretic were held on
admission and restarted prior to discharge.
INACTIVE ISSUES
#Diabetes - QID fingersticks, will start insulin if these are
presistently high.
he did not require insulin administration. Home asa was
continued. Metformin was discontinued in the setting of
hepatitis (this was changed after discharge via telephone).
.
#Hypertension - Normotensive during hospitalization. On
admission team held ace-i, diuretic given acute renal failure
but these were restarted as above. |