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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / nifedipine
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ woman with history of carotid stenosis, CAD,
fibroid uterus, GERD, hyperlipidemia, hypertension, obesity,
osteoarthritis, renal artery stenosis, venous insufficiency,
impaired fasting glucose, reactive airway disease, atrial
flutter and CHF presenting for evaluation of syncope.
History obtained from patient with help of family at bedside
interpreting. They say that she was in her usual state of health
for the day as she was doing normal activities like going to
Target. She was folding clothes at home when she developed
sudden onset, severe headache over top of the head and occiput,
no vision changes but severe lightheadedness lasting over a
couple of seconds. Witnesses deny muscle jerks, urinary/bowel
incontinence. Pt denies tongue biting. Upon awaking, pt states
she continued to have headache and LH. Soon thereafter, she had
mild chest pain on the R side of her chest pain, took a SLN with
relief. Per patient's son, BP at time of being found down was
192/115, after SLN --> 114/60.
In the ED, initial vital signs were: Vital Signs: Temp: 99.4.
Pulse: 59. RR: 18. BP: 145/61. MAP: 89.0 mm Hg. O2 sat: 96. O2
flow: Room Air. Pain: 0.
- Exam was notable for: Negative by orthostatics
- Labs were notable for: WBC, RBC WNL, mild thrombocytopenia
145, INR 3.0, Cr 1.2, AST/ALT 39/24, AP 110. Lactate 2.2
- Imaging: CTH negative for acute intracranial process. C spine
negative for fracture or malalignment. Thyroid glan with
hypodense nodules up to 4mm, similar appearance to ___. 3
mm left lung apex pulmonary nodule.
- The patient was given: Ceftriaxone 1gm
- Consults: none
Vitals prior to transfer were: Temperature 97.5 ðF (36.4
ðC).Pulse 57.Respiratory Rate 19. Blood Pressure 127/53.O2
Saturation 98.Pain Level 0.
Upon arrival to the floor, patient states that she has pain
with urination x 3 days. Also with DOE to ___ block, + PND,
+orthopnea, no swelling in her legs. Headaches stopped on
arrival. Endorses epigastric pain x 3 days, +++ constipation, no
hematochezia or melena. Endores hard pellet stool. Denies ever
having nausea/vomiting, diarrhea.
Past Medical History:
CAROTID STENOSIS s/p R STENT
CORONARY ARTERY DISEASE s/p CABG x 4V (___)
HX OF TIA
HYPERCHOLESTEROLEMIA
HYPERTENSION
OBESITY
GERD
OSTEOARTHRITIS
RENAL ARTERY STENOSIS s/p STENTING (___)
ATRIAL FLUTTER
CONGESTIVE HEART FAILURE
Social History:
___
Family History:
Her father died at age ___ in an accident. Her mother died at age
___ of liver cancer. She has one brother, two sisters, three sons
and five daughters. Most of her siblings and children have
hypertension and she has a sister with hyperlipidemia and a son
who may have sustained a stroke. There is no family history
notable for diabetes, early coronary artery disease or sudden
cardiac death.
Physical Exam:
on admission:
VITALS - 98.0 139/53 48 18 96%RA
___ 00:00, Vital Signs: Temp: supine, Pulse: 62, BP:
127/48, MAP: 74.3 mm Hg.
___ 00:02, Vital Signs: Temp: sitting, Pulse: 60, BP:
138/49, MAP: 78.7 mm Hg.
___ 00:04, Vital Signs: Temp: standing, Pulse: 62, BP:
143/51, MAP: 81.7 mm Hg.
GENERAL - pleasant, well-appearing, in no apparent distress,
NAD
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP at tragus
CARDIAC - regular rate with ectopy, bradycardidc, no murmur
appreciated on my exam. Does not appear orthopneic when lying
flat
PULMONARY - bibasilar crackles
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
BACK: +CVAT on L
NEUROLOGIC - A&Ox3, CN II-XII full tested and intact except R
strabismus that has been longstanding. Normal sensation, with
strength ___ ___ in LUE (weak d/t prior fracture on that
side). ___ hip flexion/extension, ___ ankle dorsiflexion/plantar
flexion. Negative Kernig's and Brudzinki however +neck pain with
flexion of neck and hip flexion. Gait assessment deferred.
Finger to nose intact.
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
On discharge:
VITALS - 97.7 142/66 (range SBP 189-104) 61 18 95%RA
GENERAL - pleasant, well-appearing, NAD
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
CARDIAC - regular rate with irregular rhythm, no mrg
PULMONARY - Minimal bibasilar crackles, CTAB
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
NEUROLOGIC - A&Ox3, CN II-XII full tested and intact except R
strabismus that has been longstanding. Moves all extremities
purposefully
Pertinent Results:
On admission:
___ 12:20AM BLOOD WBC-6.7 RBC-4.61 Hgb-11.2 Hct-37.0
MCV-80* MCH-24.3* MCHC-30.3* RDW-18.7* RDWSD-53.5* Plt ___
___ 12:20AM BLOOD Neuts-64.4 ___ Monos-10.3 Eos-1.9
Baso-0.6 Im ___ AbsNeut-4.33 AbsLymp-1.51 AbsMono-0.69
AbsEos-0.13 AbsBaso-0.04
___ 12:20AM BLOOD ___ PTT-45.3* ___
___ 12:20AM BLOOD Glucose-110* UreaN-27* Creat-1.2* Na-143
K-4.0 Cl-103 HCO3-27 AnGap-17
___ 12:20AM BLOOD ALT-34 AST-39 AlkPhos-110* TotBili-0.5
___ 12:20AM BLOOD Lipase-39 GGT-146*
___ 12:20AM BLOOD proBNP-2770*
___ 12:20AM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD cTropnT-<0.01
___ 12:20AM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.8 Mg-2.0
___ 07:05AM BLOOD Ferritn-24
___ 07:05AM BLOOD TSH-1.2
Micro:
___ 12:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Reports:
ECG Study Date of ___ 12:24:46 AM
Sinus rhythm with frequent premature atrial contractions. RSR'
pattern in
lead V1, probable normal variant. Extensive non-specific ST-T
wave changes.
Borderline prolonged Q-T interval. Compared to tracing #1 the
Q-T interval is more easily measured and appears prolonged.
CT HEAD W/O CONTRAST Study Date of ___ 12:17 AM
IMPRESSION:
1. No acute intracranial process. No hemorrhage or other
sequelae of trauma identified.
2. Age-appropriate global cerebral atrophy.
CT C-SPINE W/O CONTRAST Study Date of ___ 12:18 AM
IMPRESSION:
1. No fracture or malalignment.
2. Mild multilevel cervical spine degenerative change.
3. Heterogeneous thyroid gland with hypodense nodules measure up
to 5 mm,
similar appearance to ___.
4. 3 mm left lung apex pulmonary nodule. Consider follow-up if
indicated
based on risk factors.
RECOMMENDATION(S): The ___ pulmonary nodule
recommendations are intended as guidelines for follow-up and
management of newly incidentally detected pulmonary nodules
smaller than 8 mm, in patients ___ years of age or older. Low
risk patients have minimal or absent history of smoking or other
known risk factors for primary lung neoplasm. High risk patients
have a history of smoking or other known risk factors for
primary lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in
low-risk patients.
For high risk patients, recommend follow-up at 12 months and if
no change, no further imaging needed.
CTA HEAD W&W/O C & RECONS Study Date of ___ 12:29 ___
IMPRESSION:
1. No acute intracranial process without territorial infarct,
hemorrhage, or mass effect.
2. Chronic occlusion of left V3 V4 segment vertebral artery
which is unchanged comparison to ___.
3. Otherwise patent anterior and posterior circulations without
new occlusion, dissection, or vascular malformation.
4. Unchanged 2 mm aneurysm at the left vertebral basilar
junction.
5. Unchanged 3 mm aneurysm at the origin of the right posterior
communicating artery.
6. Unchanged 4 mm aneurysm at the left communicating segment
internal carotid artery, likely at the origin of the posterior
communicating artery.
7. Unchanged 2 mm aneurysm the left M1/M2 middle cerebral artery
junction.
8. Right maxillary and anterior ethmoid sinus disease, as
described.
TTE (Complete) Done ___ at 10:23:15 AM FINAL
Conclusions
The left atrial volume index is severely increased. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Doppler
parameters are indeterminate for left ventricular diastolic
function. The right ventricular cavity is mildly dilated with
normal free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular wall thickness, cavity size
and regional/global systolic function. Mild right ventricular
cavity dilatation with preserved systolic function. Severe
pulmonary hypertension. Mild mitral and aortic regurgitatin.
Compared with the prior study (images reviewed) of ___,
the severity of pulmonary hypertension has progressed. There are
now signs of RV pressure and volume overload.
Labs on discharge:
___ 06:46AM BLOOD ___
___ 06:46AM BLOOD Glucose-110* UreaN-25* Creat-1.1 Na-138
K-3.9 Cl-99 HCO3-28 AnGap-15
___ 06:46AM BLOOD Calcium-9.4 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Warfarin 5 mg PO 4X/WEEK (___)
5. Warfarin 2.5 mg PO 3X/WEEK (___)
6. HydrALAzine 100 mg PO TID
7. Simvastatin 40 mg PO QPM
8. Furosemide 40 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Losartan Potassium 150 mg PO DAILY
RX *losartan 50 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
4. Furosemide 40 mg PO DAILY
5. HydrALAzine 100 mg PO TID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Prescription
Please provide patient with Cane
Dx: Osteoarthritis ICD-9 175 ICD-10 M15.9
Prognosis: Good
Length: 13 mo
13. Outpatient Lab Work
I48.0 Paroxysmal atrial fibrillation
Please draw INR on ___
Please fax results to ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Vasovagal syncope
Acute on chronic diastolic heart failure
Hypertensive emergency
Complicated urinary tract infection
Constipation
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
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with syncope, head strike, loss of
consciousness, evaluate for fracture or bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 14.0 s, 14.9 cm; CTDIvol = 47.1 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Dural falx calcifications are noted.
There is no evidence of fracture. There is ethmoid air cell and right
maxillary sinus mucosal thickening. The right ostiomeatal unit is occluded
due to mucosal thickening. The remaining imaged paranasal sinuses are clear.
The visualized portion of the mastoid air cells and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process. No hemorrhage or other sequelae of trauma
identified.
2. Age-appropriate global cerebral atrophy.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ woman with syncope resulting in head strike, evaluate
for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 18.6 cm; CTDIvol = 36.7 mGy (Body) DLP = 681.9
mGy-cm.
Total DLP (Body) = 682 mGy-cm.
COMPARISON: CTA head and neck ___.
FINDINGS:
There is no fracture or malalignment. There is no prevertebral fluid or soft
tissue swelling. There is mild multilevel cervical spine degenerative change.
There is no significant spinal canal or neural foraminal narrowing. There is
no cervical lymphadenopathy. A heterogeneously enhancing thyroid gland with
hypodense thyroid nodules measuring up to 5 mm is noted (series 3, image 46),
similar in appearance to prior CTA neck from ___. A right
carotid stent is noted. A 3 mm pulmonary nodules noted at the medial left
lung apex (series 3, image 55).
IMPRESSION:
1. No fracture or malalignment.
2. Mild multilevel cervical spine degenerative change.
3. Heterogeneous thyroid gland with hypodense nodules measure up to 5 mm,
similar appearance to ___.
4. 3 mm left lung apex pulmonary nodule. Consider follow-up if indicated
based on risk factors.
RECOMMENDATION(S): The ___ pulmonary nodule recommendations
are intended as guidelines for follow-up and management of newly incidentally
detected pulmonary nodules smaller than 8 mm, in patients ___ years of age or
older. Low risk patients have minimal or absent history of smoking or other
known risk factors for primary lung neoplasm. High risk patients have a
history of smoking or other known risk factors for primary lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if no change, no
further imaging needed.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ female wing with right parietal occipital headache
associated with a syncopal event. Evaluate for intracranial hemorrhage.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.4 s, 18.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
954.0 mGy-cm.
2) Stationary Acquisition 11.4 s, 0.5 cm; CTDIvol = 173.3 mGy (Head) DLP =
86.7 mGy-cm.
3) Spiral Acquisition 6.6 s, 21.2 cm; CTDIvol = 30.7 mGy (Head) DLP = 651.9
mGy-cm.
Total DLP (Head) = 1,693 mGy-cm.
COMPARISON: ___ noncontrast head CT. ___ head and neck
CTA.
FINDINGS:
CT head: The gray-white matter differentiation is intact without acute
territorial infarct, hemorrhage, or mass effect. There is nonspecific
periventricular deep white are hypodensity, likely reflecting sequela of
chronic microangiopathy. The ventricles cortical sulci are normal caliber
configuration. The extra-axial spaces are unremarkable.
The orbits, soft tissues, and calvarium are unremarkable. There is marked
mucosal thickening of the right maxillary sinus and partial opacification of
the anterior right ethmoid sinus. The mastoid air cells and middle ears are
clear.
CTA head: There is a tortuous course of the right cervical segment internal
carotid artery with partial visualization of atherosclerosis at the proximal
external and internal carotid arteries. There is partially visualized
atherosclerosis at the left carotid bifurcation bulb. The bilateral posterior
communicating arteries are visualized. The anterior communicating artery is
not definitively seen. There is a right fetal origin posterior cerebral
artery. There is a right dominant vertebral artery. There is absent time of
the left V3 and V4 segment vertebral artery with diminished filling of the V2
segment which is unchanged comparison ___, consistent with
chronic occlusion.
There is a 2 mm outpouching at the left vertebrobasilar junction, likely
representing an aneurysm.
There is a 3 mm posterior and inferiorly projecting aneurysm at the origin of
the right posterior communicating artery (602bO:20).
There is a 4 mm posterior and inferiorly projecting aneurysm at the left
communicating segment internal carotid artery which may be at the origin of
the posterior communicating artery (6:87; 602bO:29).
There is a 2 mm superiorly projecting aneurysm at the left M1/M2 middle
cerebral artery junction (6:96; 6 02:36).
The anterior and posterior circulations are patent without occlusion,
dissection, or significant stenosis. There is no evidence of vascular
malformation.
IMPRESSION:
1. No acute intracranial process without territorial infarct, hemorrhage, or
mass effect.
2. Chronic occlusion of left V3 V4 segment vertebral artery which is unchanged
comparison to ___.
3. Otherwise patent anterior and posterior circulations without new occlusion,
dissection, or vascular malformation.
4. Unchanged 2 mm aneurysm at the left vertebral basilar junction.
5. Unchanged 3 mm aneurysm at the origin of the right posterior communicating
artery.
6. Unchanged 4 mm aneurysm at the left communicating segment internal carotid
artery, likely at the origin of the posterior communicating artery.
7. Unchanged 2 mm aneurysm the left M1/M2 middle cerebral artery junction.
8. Right maxillary and anterior ethmoid sinus disease, as described.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: s/p Fall, Head injury
Diagnosed with Syncope and collapse
temperature: 99.4
heartrate: 59.0
resprate: 18.0
o2sat: 96.0
sbp: 145.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ woman with CAD s/p CABG, diastolic
heart failure with 1+ AI and 1+ MR, poorly controlled
hypertension, dyslipidemia, atrial fibrillation, atrial
flutter/palpitations, peripheral vascular disease, borderline
diabetes, renal artery stenosis, venous insufficiency,
degenerative joint disease, TIA and morbid obesity who presents
with episode of syncope at home.
# Syncope: She syncopized while she was folding towels at home.
The patient noted a HA prior to the event, and some CP
following. She was noted to be hypertensive during the event as
well. Her HTN and CP resolved with SLNTG. She had a NCHCT as
well as a CTA of her head which were negative for ICH/ SAH. She
was monitored on telemetry and had no evidence of VT or rapid
ventricular response with hypotension to explain her event. She
underwent TTE which showed no AS or other valvular abnormalities
which would explain her syncope. She did have evidence of PAH
and RV dysfunction, as well as ___ c/w her known AF.
With no identifiable cause identified, this likely represents
vasovagal syncope. If she has a recurrence of syncope, it would
be reasonable to consider holter monitoring given her extensive
cardiac history.
# Hypertensive emergency: Pt was noted to be hypertensive with
her initial headache preceding the event, which improved with x1
dose of SLNTG. She was managed on her home hydralazine and
losartan while in house. She intermittently required IV
hydralazine for SBP in the 190's, though she was asymptomatic
and at rest during these periods. She should likely have
uptitration of her antihypertensive regimen on an outpatient
basis.
# Acute on chronic diastolic heart failure (1+AI, 1+MR): Ms
___ was noted to be volume overloaded on exam with bibasilar
crackles upon admission. She received PO and IV furosemide
during her stay, which improved her exam until she was
euvolemic. She was then transitioned back to her home 40mg PO
Lasix daily and this should be followed and titrated over time.
Her weight on discharge was 71.7 kg.
# Complicated UTI: UA positive on admission with minimal CVAT
on exam. She was treated with 5d of IV ceftriaxone.
# Chronic constipation: the patient has known constipation and
was complaining of upper abd pain c/w her prior constipation.
She was given lactulose which helped her have multiple BM's,
which improved her pain. She was continued on her home bowel
regimen upon discharge.
# Atrial fibrillation (status post surgical PVI with resection
___ in ___. c/b TIA: The patient's coumadin was adjusted
for ease of home dosing to 3mg QD. Additionally, her carvedilol
was held while in house given her persistent bradycardia to the
50's at rest. She was able to augment her HR with exercise. Thus
her carvedilol was held upon discharge pending follow-up with
her PCP and cardiology.
CHRONIC ISSUES
# Coronary artery disease (status post four-vessel CABG, LIMA
to LAD, SVG to D1, SVG to OM1, SVG to ramus, NSTEMI ___: home aspirin, losartan, simvastatin were continued. The
patient's home carvedilol was held given her bradycardia.
# Dyslipidemia: Continued simvastatin 40 mg qd
Transitional issues
#Incidentally, on CT C-spine a 3 mm left lung apex pulmonary
nodule was identified, she will need repeat chest imaging in the
future and follow-up of this nodule if indicated based on risk
factors and smoking history
#She finished a course of ceftriaxone for complicated UTI while
in house
#Pt will have neurology f/u for multiple aneurysms seen on CTA
which was never followed up previously
#Pt will be set up with cardiology and pulmonology follow-up for
markedly elevated PASP, ___ and changes seen on TTE
#If the patient has recurrent syncope, consider Holter monitor
in the future
#Standing weight on discharge: 71.7 kg
#Sent out on this Lasix dose: 40mg PO QD
#Pt should have electrolytes checked at next PCP ___
#Patient's home carvedilol was held during this admission given
her bradycardia during her stay
#The patient's warfarin was changed to 3mg daily to ease
administration
#patient should have her INR checked on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Red eye
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with ESRD on dialysis presents with red and
painful right eye. Ocular symptoms started at 3AM on ___
while she was sleeping. Denies trauma or foreign body sensation.
She had right eye pain with motion that has since improved.
Vision is worse with reading. No photophobia. Denies
crusting/exudate. No associated headache, fever or chills. Does
not wear contacts. No history of red/painful eye in the past. No
sick contacts. She had one episode of vomiting in the ED that
she reported to be brown, but ED staff reported as coffee
grounds, no gastroccult testing avaiable. Mild residual nausea.
No abdominal pain or recent bloody stools. No recent vomitting,
but she has a history of hospitalization at ___ ___ for
GERD/PUD.
In the ED, initial VS were: Exam notable for irregular shaped R
pupil, pain w/ eye movement, no perilimbic spraring, ocular
pressure 12 OD, visual acuity ___ OD/OS, no corneal abrasions,
no cell or flare. Labs notable for AST 49, AP 184, HCT 52, Cr
5.5, K 6.4 (hemolyzed), glucose 406. She had an episode of
hematemesis while in the ED. GI was consulted. She received PPI
40mg IV. Rectal exam guaiac negative. VS prior to transfer were:
On arrival to the floor, she is comfortable with mild right eye
pain and some nausea.
REVIEW OF SYSTEMS:
Denies nasal congestion, sore throat, cough, chest pain,
dysuria, hematuria.
Past Medical History:
- ESRD on dialysis - on HD ___
- diabetes mellitus
- proliferative retinopathy
- GERD
- PUD ___
- meningioma, s/p resection ___ with resultant seizures
- Whipple ___ for pancreatic lesion
Social History:
___
Family History:
Mother HTN/CVA
Sister HTN/CVA
Daughter DM2
Father stomach CA
Physical Exam:
ADMISSION EXAM:
VITALS: 98.4 126/84 84 16 93%RA
GENERAL: NAD, pleasant
HEENT: PERRL, EOMI without pain, right eye with conjuctival
erythema, no exudate, MMM
NECK: no carotid bruits, no LAD, no JVD
LUNGS: CTAB, no W/R/R
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
DISCHARGE EXAM:
VITALS: 97.4/98.2; 94-104/46-56; 57-64; 16; 100RA
HEENT: PERRL, EOMI without pain, b/l eyes with conjuctival
erythema R>L, no exudate
Exam otherwise unchanged since admission
Pertinent Results:
ADMISSION LABS:
___ 10:30PM BLOOD WBC-8.9 RBC-5.80*# Hgb-16.2*# Hct-52.1*#
MCV-90 MCH-27.9 MCHC-31.0 RDW-16.1* Plt ___
___ 10:30PM BLOOD Glucose-406* UreaN-29* Creat-5.5* Na-136
K-6.4* Cl-91* HCO3-23 AnGap-28*
___ 10:30PM BLOOD ALT-22 AST-49* AlkPhos-184* TotBili-0.4
___ 07:15PM BLOOD CK(CPK)-34
___ 07:50AM BLOOD Calcium-9.5 Phos-5.3* Mg-2.5
___ 10:30PM BLOOD Albumin-4.4
___ 05:45AM BLOOD ASA-NEG Acetmnp-NEG
___ 08:34PM BLOOD Lactate-1.3
___ 05:45AM BLOOD Osmolal-308
CARDIAC ENZYMES:
___ 10:45AM BLOOD CK-MB-2 cTropnT-0.03*
___ 07:15PM BLOOD CK-MB-2 cTropnT-0.03*
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-9.1 RBC-5.36 Hgb-15.2 Hct-48.6*
MCV-91 MCH-28.3 MCHC-31.2 RDW-15.9* Plt ___
___ 05:45AM BLOOD ___ PTT-32.8 ___
___ 05:45AM BLOOD Glucose-302* UreaN-52* Creat-8.1* Na-132*
K-5.3* Cl-90* HCO3-18* AnGap-29*
___ 05:45AM BLOOD Calcium-9.3 Phos-5.5* Mg-2.6
MICROBIOLOGY:
H. pylori: negative
IMAGING:
REASON FOR EXAMINATION: Eye abnormality and suspected hilar
lymphadenopathy due to sarcoidosis.
The heart size is normal. Within the limitations of this
portable radiograph, no evidence of mediastinal lymphadenopathy
is present. The lungs are well inflated. Left basal opacity is
noted, potentially representing atelectasis, but infectious
process cannot be excluded. Line projecting over the left
hemithorax most likely represents VP shunt, please correlate
clinically.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Calcium Acetate 667 mg PO TID W/MEALS
2. esomeprazole magnesium *NF* 40 mg Oral BID
3. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. LeVETiracetam 1000 mg PO BID
5. Simvastatin 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Metoclopramide 5 mg PO TID
9. Cinacalcet 90 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Lactulose 30 mL PO BID:PRN constipation
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Diltiazem Extended-Release 180 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Cinacalcet 90 mg PO DAILY
4. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. LeVETiracetam 1000 mg PO BID
6. Metoclopramide 5 mg PO TID
7. Nephrocaps 1 CAP PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Simvastatin 40 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Diltiazem Extended-Release 180 mg PO DAILY
12. Esomeprazole Magnesium *NF* 40 mg ORAL BID
13. Lactulose 30 mL PO BID:PRN constipation
14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
last day ___
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch(s) eye
four times a day Disp #*1 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Conjunctivitis
Atrial fibrillation with rapid ventricular rate
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Eye abnormality and suspected hilar lymphadenopathy
due to sarcoidosis.
AP radiograph of the chest was reviewed with no prior studies available for
comparison.
The heart size is normal. Within the limitations of this portable radiograph,
no evidence of mediastinal lymphadenopathy is present. The lungs are well
inflated. Left basal opacity is noted, potentially representing atelectasis,
but infectious process cannot be excluded. Line projecting over the left
hemithorax most likely represents VP shunt, please correlate clinically.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RIGHT EYE REDNESS/PAIN
Diagnosed with PAIN IN OR AROUND EYE, REDNESS/DISCHARGE OF EYE, HEMATEMESIS, DIAB RENAL MANIF IDDM, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.2
heartrate: 78.0
resprate: 18.0
o2sat: 96.0
sbp: 117.0
dbp: 53.0
level of pain: 4
level of acuity: 3.0 | ___ year old woman with ESRD on dialysis presents with red and
painful right eye.
# Conjunctivitis: Patient initially presented with red and
painful red eye, no discharge, no blurry vision, but does
endorse more pain with movement of the eye. DDx included
conjunctivitis or iritis. No evidence of acute angle glaucoma
given lack of headache and normal ocular pressures in the ED. No
corneal abraisons were seen on slit lamp exam. Patient started
on erythromycin gel for treatment of conjunctivitis.
Ophthalmology saw the patient and agreed with treatment as there
was low concern for uveitis. During the hospital course,
redness also spread to the left eye, so erythromycin gel applied
bilaterally. Given improvement with topical antibiotics,
steroids were not considered. Plan total 7 day course (last day
___. Asked patient to follow up with her outpatient
ophthalmologist if symptoms do not resolve in ___ days.
# Paroxysmal afib: Patient with paroxysmal afib on dilt and
metoprolol for rate control/rhythm maintenance. EKG with NSR in
___ on presentation to ED. However, on admission to the floor,
patient with afib with rates in 130-140s. This was likely due
to missing medication (patient does not take AM meds on HD days,
then did not have meds in the ED and arrived on the floor in the
early AM with RVR). Patient afebrile with no evidence of
infection. ___ with cardiac enzymes negative x2 (has stably
elevated troponin at 0.02 with CKD, but normal CKMB). Rapid
ventricular rate controlled with IV metop 7.5mg, followed by
home meds (dilt XR 180mg daily and metop XL 12.5mg daily.)
Patient spontaneously converted to NSR with rates in high ___,
so metop was discontinued. CHADS=2. Not on anticoagulation.
Per patient, she has been diagnosed with afib on multiple prior
ED visits, but her PCP is not aware. Plan to continue dilt XR
180mg daily, but not to initiate anticoagulation till PCP follow
up.
# Vomiting with possible UGIB: Reported coffee ground emesis in
the ED, although patient states vomit looked brown. Her HCT is
52 and stool guaiac negative. She has a history of GERD and PUD
and is at risk for recurrence although she is taking a PPI at
home. Differential also includes ___ tear. BID hct
stable high ___. No additional episodes of vomiting since
admission to the floor. Patient continued on PPI and plan to
follow up with outpatient gastroenterologist for resolution of
PUD.
# ESRD on HD: Last HD on ___ prior to presentation to ED.
Electrolytes stable (K 5.3 at discharge, day prior to next HD
session). No urgent indications for HD during this
hospitalization ___ to ___. Plan to resume regular
outpt HD MWF on discharge.
# DM2: Continued home lantus and SSI.
# GERD: Continued PPI and reglan.
# HLD: Continued simvastatin.
# H/o seizures: Continued keppra.
# Transitional issues:
- code status: full
- pending labs: none
- medication changes: stopped metoprolol
- follow up: with PCP, follow up issues include paroxysmal afib
- follow up: with hemodialysis and nephrology
- follow up: ophthalmology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ with CKD, HTN, RV failure and severe PAH from
suspected connective tissue disease/limited SSc, diagnosed by
RHC ___ (mPAP 48, PVR 12.5), with CI 1.6 and RAP 23. She is
being referred by Dr. ___ volume overload, diuresis.
She has been gaining fluid weight over the past several weeks.
Despite taking total 60mg torsemide daily patient has been
retaining fluid. She has had low energy, been incontinent of
urine, and has not been doing well at home. Dr. ___
___ patient with daughter ___, recommended inpatient
management of volume overload given patient has been refusing
higher doses of diuretics at home secondary to intermittent
incontinence and would require frequent laboratory draws. ___
has brought her macitentan with her.
Most recently seen in ___ clinic ___ where she weighed 157
lbs, noted to have difficulty walking room to room but not
overly limiting, severe difficulty with stairs. She was using
oxygen more frequently, often 24 hours/day. Her O2 sat in clinic
was 91% 2L. Usually she uses it with sleep and activity. It was
recommended that she f/u with ___ rheumatology as it is
easier for her to get to.
Recent hospitalization in ___ notable for severe volume
overload/ p-HTN, HFpEF exacerbation. She was started on
sildenafil and macitentan for pHTN. Was very volume overloaded
on admission and treated with lasix drip and metolazone for
several days. She had difficult access requiring a CVL, hand
arthritis that was responsive to steroids, and an E.coli UTI.
In the ED intial vitals were: 97.3 70 115/56 20 96% on 2L. Labs
with trop 0.09, CXR w/ pulmonary edema, lactate 2.6. A R-EJ was
placed.
Patient was given: percocet for leg pain.
Vitals on transfer: 97.5 74 121/60 17 99% RA
On the floor patient complaining of severe back pain from base
of neck to mid back. States pain began 2 weeks ago when she was
sitting down into chair and sat down faster than intended
hitting chair hard. She did not hear any cracks, pops. She has
not noted any lower extremity weakness, paresthesias. She has
had difficulty walking and attributes this to her legs feeling
heavy, not weak. She has had urinary incontinence since
increasing torsemide, stands up to go to the bathroom and urine
comes out beyond her control. No incontinence of stool. Has been
taking percocet with good effect.
She has not had chest pain, palpitations. She denies shortness
of breath, cough, wheezing. She wears O2 at all times at home,
on 2L NC. She sleeps flat in bed on 1 pillow, no orthopnea or
PND.
ROS: On review of systems, she denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, cough, hemoptysis,
black stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
- PAH, suspected secondary to CTD/limited SSc. Diagnosed by RHC
___ (mPAP 48, PVR 12.5), with reduced CI and RAP 23 at
diagnosis. Required hospitalization for diuresis and sildenafil
initiation just afterwards
- Positive ___, high titer with anti centromere positivity, and
?Raynaud's (cold fingers, very difficult to pick up oximetry x
years), with PAH concerning for limited scleroderma
- Hypertension
- Chronic renal insufficiency, unclear cause.
- Hyperlipidemia
- Osteoarthritis. Involving back, knees. History of spinal
stenosis and s/p laminectomy in the past.
- Obesity
- Gout
Social History:
___
Family History:
Mother died of heart disease, Son and brother with CAD. No
family hx of pulmonary hypertension or VTE
Physical Exam:
===========================
PHYSICAL EXAM ON ADMISSION:
===========================
VS: T=97.6 129/71 103 18 92% on 2L
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
Poor dentition.
NECK: Supple with JVP of 12-13cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. tachycardic, S1, S2 with systolic murmur best appreciated
at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bilateral
bases, no wheezes or rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. +BS
EXTREMITIES: 4+ pitting edema in bilateral lower extremities to
knees. Bilateral well healed knee scars. Right foot with plantar
surface 1cm ulceration without erythema, purulent drainage.
Thoracic spine with tenderness to palpation, no ecchymosis or
swelling.
SKIN: No stasis dermatitis or xanthomas. Scars on bilateral
knees as above; R plantar surface ulceration as above.
NEURO: axox3, cnII-XII grossly intact, bilateral lower extremity
strenth and sensation to light touch intact, no saddle
anesthesia, rectal tone intact
============================
PHYSICAL EXAM ON DISCHARGE:
============================
Vital Signs: 97.8/98.6 94/53 (___) 59 (50-60) 20 95% on
RA
Wt:62.1kg (136lbs) <- 63.6kg (140.2lbs) <-65.7
(144.8lbs)<-66.5kg <- <-70.2kg <-71.9 kg
Telemetry: NSR, no significant alarms HR ___
General: older woman lying in bed, comfortable appearing,
speaking in full sentences, breathing comfortably on RA, no
acute distress
HEENT: PERRL, MMM, oropharynx without erythema or exudate, poor
dentition
Lungs: CTAB no wheezes or rhonchi
CV: regular rate and rhythm, II/VI holosystolic murmur best
appreciated at LLSB, JVP at 9-10cm
Abdomen: obese, soft, non distended, non tender to deep
palpation, normoactive bowel sounds
Ext: no tenderness to palpation of thoracic spine, no paraspinal
muscle tenderness. Improved bilateral lower extremity swelling,
trace edema bilaterally; Left third digit with improved PIP and
MCP erythema, warmth, swelling; tenderness to palpation of
bilateral lower extremities
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 03:20PM WBC-9.6 RBC-4.07* HGB-13.2 HCT-40.3 MCV-99*
MCH-32.4* MCHC-32.7 RDW-17.4*
___ 03:20PM GLUCOSE-135* UREA N-37* CREAT-2.1* SODIUM-139
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 03:20PM PHOSPHATE-3.1 MAGNESIUM-2.0
___ 03:20PM cTropnT-0.09* ___
___ 03:53PM LACTATE-2.6*
___ 03:20PM BLOOD cTropnT-0.09* ___
===============
PERTINENT LABS:
===============
___ 03:20PM BLOOD cTropnT-0.09* ___
___ 12:50AM BLOOD CK-MB-4 cTropnT-0.07*
___ 10:31PM BLOOD UricAcd-11.8*
SCL-70 ANTIBODY <1.0 NEG <1.0 NEG AI
RNA POLYMERASE III AB <20 <20 Units
==================
LABS ON DISCHARGE:
==================
___ 05:15AM BLOOD Glucose-80 UreaN-66* Creat-2.0* Na-139
K-4.6 Cl-95* HCO3-30 AnGap-19
___ 05:15AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.4
EKG:
Sinus rhythm. Compared to the previous tracing the heart rate is
reduced.
Otherwise, multiple abnormalities as previously described
persist without major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 186 82 ___ -11
=============
MICROBIOLOGY:
=============
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
=========
STUDIES:
=========
CXR ___:
FINDINGS:
The heart is mildly enlarged with a left ventricular
configuration. The
cardiac, mediastinal and hilar contours appear stable. There is
no pleural
effusion or pneumothorax. Diffuse opacification is most
suggestive of
moderate pulmonary edema.
IMPRESSION:
Findings consistent with pulmonary edema
T Spine xray ___:
FINDINGS:
The thoracic spine is unable to be adequately evaluated on this
radiograph,
due to severe osteopenia and overlapping lung parenchymal
pathology.
IMPRESSION:
Thoracic spine is not adequately evaluated on this radiograph
due to severe
osteopenia and overlapping lung parenchymal pathology. A CT of
the thoracic
spine is therefore recommended for further evaluation.
TTE ___:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferoseptal segment.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. Trivial mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Dilated, hypokinetic right ventricle with abnormal
septal motion and severe pulmonary artery systolic hypertension
consistent with primary pulmonary process (e.g. pulmonary
embolus, COPD, etc.) Mildly depressed left ventricular systolic
function with regional wall motion abnormalities, as described
above. Increased left ventricular filling pressure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Potassium Chloride 10 mEq PO DAILY
4. Docusate Sodium 100 mg PO TID
5. Sildenafil 20 mg PO TID
6. Atorvastatin 10 mg PO HS
7. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
9. Torsemide 20 mg PO BID
10. Opsumit (macitentan) 10 mg oral QD
11. Senna 8.6 mg PO BID:PRN constipation
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H wheeze, dyspnea
Discharge Medications:
1. Atorvastatin 10 mg PO HS
2. Docusate Sodium 100 mg PO TID
3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H wheeze, dyspnea
4. Opsumit (macitentan) 10 mg oral QD
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
6. PredniSONE 5 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Sildenafil 20 mg PO TID
9. Torsemide 20 mg PO BID
10. Bisacodyl ___AILY:PRN constipation
11. Colchicine 0.3 mg PO DAILY
12. Lactulose 30 mL PO BID:PRN constipation
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Potassium Chloride 10 mEq PO DAILY
16. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute on Chronic Diastolic Heart Failure
Exacerbation
Secondary Diagnosis: Pulmonary Artery Hypertension
Acute Gout Flare
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Increased edema.
TECHNIQUE: Chest, AP and lateral.
COMPARISON: ___.
FINDINGS:
The heart is mildly enlarged with a left ventricular configuration. The
cardiac, mediastinal and hilar contours appear stable. There is no pleural
effusion or pneumothorax. Diffuse opacification is most suggestive of
moderate pulmonary edema.
IMPRESSION:
Findings consistent with pulmonary edema.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old woman s/p fall into chair complaining of severe back
pain in thoracic spine. +urinary incontinence. No lower extremity weakness or
paresthesias.
TECHNIQUE: Thoracic spine, two views.
COMPARISON: PA lateral chest x-ray from ___ and ___.
FINDINGS:
The thoracic spine is unable to be adequately evaluated on this radiograph,
due to severe osteopenia and overlapping lung parenchymal pathology.
IMPRESSION:
Thoracic spine is not adequately evaluated on this radiograph due to severe
osteopenia and overlapping lung parenchymal pathology. A CT of the thoracic
spine is therefore recommended for further evaluation.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with RV failure, bilateral lower extremity L>R
with tenderness to palpation // LLE DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
INDICATION: ___ female with new PICC.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Single portable AP chest radiograph demonstrates interval placement of a right
PICC which appears to terminate at the junction of the right subclavian and
superior vena cava. For placement within the mid superior vena cava, recommend
advancement 3cm. Heart size is stably enlarged. Descending aorta appears
tortuous. There is no large pleural effusion or pneumothorax. No focal opacity
convincing for pneumonia is identified.
IMPRESSION:
Right PICC terminating at the junction of the right subclavian and superior
vena cava. For more appropriate position, recommend advancement 3 cm. Heart
size stably enlarged.
NOTIFICATION: These findings were communicated to the IV nurse ___
___ by Dr. ___ telephone at 16:21 on ___ at the time
study was reviewed.
Radiology Report
INDICATION: Right PICC line.
TECHNIQUE: Single portable frontal radiograph of the chest.
COMPARISON: Chest radiograph from ___
FINDINGS:
A right upper extremity PICC line terminates in the proximal right atrium. No
focal consolidation is identified. The heart size is mildly enlarged. There is
no pleural effusion or pneumothorax.
IMPRESSION:
Right upper extremity PICC line terminates in the proximal right atrium. If
positioning at the cavoatrial junction is desired, the PICC line may be pulled
back by 2 cm.
NOTIFICATION: Findings were paged to IV team by ___ at 12:15pm on
___.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with right heart failure PAH s/p PICC placement
// PICC in place? Contact name: ___: ___
TECHNIQUE: Portable AP radiograph of the chest from ___.
COMPARISON: ___.
FINDINGS:
The right-sided PICC line has been withdrawn, and now terminates in the lower
SVC. There is no pneumothorax. There is no focal consolidation or pleural
effusion. Mild cardiomegaly is unchanged. The mediastinal contours are stable.
IMPRESSION:
Right PICC line has been repositioned and now terminates in the low SVC.
Otherwise no significant interval change from the study of 2 days prior.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hand swelling, Leg swelling
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 97.3
heartrate: 70.0
resprate: 20.0
o2sat: 96.0
sbp: 115.0
dbp: 56.0
level of pain: 10
level of acuity: 3.0 | ___ year old woman with RV failure and severe PAH from suspected
connective tissue disease/limited SSc, diagnosed by RHC ___
(mPAP 48, PVR 12.5), with CI 1.6 and RAP 23, CKD, HTN,
presenting with worsening lower extremity swelling, increased O2
requirement, found to have significant volume overload on exam,
elevated BNP, CXR with pulmonary edema consistent with acute
heart right failure exacerbation. Course complicated by apparent
gout flare. Patient diuresed well with lasix gtt at
15mg/hr->20mg/hr, transitioned to PO toresmide on discharge at
dry weight 136lbs.
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cephalosporins
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with pMHx significant for peripheral neuropathy,
hemochromatosis, HTN, HLD presenting with L foot pain, erythema
and edema x4 days.
Patient has a history of a L distal fibula fracture since ___. He has been ambulatory, walking 10 miles per day 4 days
ago. However, for the past few days he has noted the pain,
erythema and edema and has not been able to ambulate on the leg.
He presented to an urgent care yesterday and was given Augmentin
500mg PO BID (took three doses) and represented to urgent care
today and was referred to ___ for IV antibiotics. He states
that he believes from yesterday into today the redness spread
but the pain improved.
In the ED initial vitals were: 97.8 58 168/86 16 100% RA
Labs were all unnotable and xray was significant only for soft
tissue swelling. He was given IV Vanc and Zosyn as well as 1L
LR.
On the floor, all vitals were stable and he had minimal LLE
pain.
Past Medical History:
Non-diabetic peripheral neuropathy
Hemochromatosis
Prostate cancer s/p surgery
Hyperlipidemia
Hypertension
Gout
Depression
Asthma
Social History:
___
Family History:
Father with MI and likely hemochromatosis
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 97.8 58 168/86 16 100% RA
GENERAL: NAD
HEENT: AT/NC
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
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
LLE- erythema outlined and includes most of foot but does not
extend much beyond the ankle, edema, large 2cm popped blister
with skin still covering and exudate noted
PHYSICAL EXAM ON DISCHARGE:
Vitals: T 97.9 HR 52 BP 142/75 RR 18
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, significant hammer toes
bilaterally with onchyomycosis and several calluses, Over the
lateral aspect of the left foot there is a callus and ulcer from
a lysed blister. There is erythema and warmth over the dorsum of
the foot which is decreased from line drawn around erythema in
ED. Decreased sensation from ankles to toes bilaterally.
Wound was explored and is very superficial
Pertinent Results:
LABS ON ADMISSION:
___ 09:58PM BLOOD WBC-8.3 RBC-4.17* Hgb-13.8* Hct-39.7*
MCV-95 MCH-33.1* MCHC-34.7 RDW-13.5 Plt ___
___ 09:58PM BLOOD Neuts-63.5 ___ Monos-6.4 Eos-3.3
Baso-0.3
___ 09:58PM BLOOD ___ PTT-28.8 ___
___ 09:58PM BLOOD Glucose-99 UreaN-13 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 09:58PM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
___ 09:30PM BLOOD Lactate-1.9
.
LABS ON DISCHARGE
___ 07:45AM BLOOD WBC-5.9 RBC-3.93* Hgb-13.1* Hct-37.8*
MCV-96 MCH-33.4* MCHC-34.8 RDW-13.5 Plt ___
___ 07:45AM BLOOD Neuts-62.7 ___ Monos-6.2 Eos-5.1*
Baso-0.4
___ 07:45AM BLOOD ___ PTT-29.1 ___
___ 07:45AM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-26 AnGap-16
___ 07:45AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1
___ 07:45AM BLOOD VitB12-442
___ 07:45AM BLOOD CRP-34.8*
___ 08:37AM BLOOD %HbA1c-PND
___ 07:45AM BLOOD SED RATE-PND
.
IMAGING:
TIB/FIB (AP & LAT) LEFT Xray:
AP and lateral views of the left tibia and fibula were provided.
There is a deformity of the left distal fibula with subtle
fracture lucency and callus formation noted indicative of a
healing fracture. Mild overlying soft tissue swelling is noted.
Ankle mortise appears grossly symmetric. Mild spurring is seen
at the distal tibia on the lateral projection. . No soft tissue
gas or radiopaque foreign body. Minimal vascular calcification
noted. Limited views of the left knee are unremarkable.
IMPRESSION:
Healing fracture of the left distal fibula. Mild overlying soft
tissue
swelling.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Sildenafil 100 mg PO DAILY:PRN sexual encounter
6. Aspirin 81 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg oral prn
insomnia
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Advil ___ (ibuprofen-diphenhydramine cit) 200-38 mg oral prn
insomnia
10. Sildenafil 100 mg PO DAILY:PRN sexual encounter
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
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
INDICATION: ___ with cellulitis nonhealing fx // eval non-healing fibula fx
COMPARISON: None.
FINDINGS:
AP and lateral views of the left tibia and fibula were provided. There is a
deformity of the left distal fibula with subtle fracture lucency and callus
formation noted indicative of a healing fracture. Mild overlying soft tissue
swelling is noted. Ankle mortise appears grossly symmetric. Mild spurring is
seen at the distal tibia on the lateral projection. . No soft tissue gas or
radiopaque foreign body. Minimal vascular calcification noted. Limited views
of the left knee are unremarkable.
IMPRESSION:
Healing fracture of the left distal fibula. Mild overlying soft tissue
swelling.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Foot pain, Cellulitis
Diagnosed with CELLULITIS OF FOOT, HYPERTENSION NOS
temperature: 97.8
heartrate: 58.0
resprate: 16.0
o2sat: 100.0
sbp: 168.0
dbp: 86.0
level of pain: 3
level of acuity: 3.0 | ___ year old male with history of peripheral neuropathy,
hemochromatosis, HTN, HLD and healing L fibula fracture
presented with cellulitis.
.
#Cellulitis - the patient had a callous on the lateral side of
his right foot and then developed erythema, edema, and warmth
over the area consistent with cellulitis 4 days prior to
admission. He has a lesion from a blister which was probed and
is superficial. His Xray showed a healing left fibula fracture
and only soft tissue swelling with no evidence of osteomyelitis.
He was initially given vancomycin and zosyn in the ED. On day 2
of admission, the cellulitis was diminished. He had minimal
pain. Osteomyelitis is unlikely given the superficial nature of
the lesion, rapid improvement, and lack of pain over the bone.
The patient was discharged on Bactrim DS BID for 7 days in
addition to the augmentin prescription he was prescribed at
urgent care. He was told to follow up with his PCP and podiatry
next week. He should have ongoing care with podiatry given his
neuropathy and structural problems with his feet.
.
# Hypertension - continued home dose lisinopril
.
# Hyperlipidemia - continued home dose simvastatin
.
# Depression - continued home dose citalopram
.
# Gout - continued home dose allopurinol |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
tachycardia, cough
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ yo male with h/o schizophrenia, ___ disease, hx of
abdominal lymphoma, HTN, HLD, t2DM p/w Afib RVR.
.
Pt was recently admitted from ___ with SBO, discharged
with ___. He was initially doing well but starting on ___, ___
noted that HR was increasing to 110-130s. He was seen in clinic
on ___ for his tachycardia. Per documentation, pt was in sinus
rhythm with rate of 129, though EKG not currently uploaded so
unable to confirm. Given that he was HD stable and asymptomatic,
pt was discharged with instructions to continue his metoprolol
at previous dose of 200 mg. He returned to his PCP's office
today for ongoing monitoring, was noted still to be tachycardic,
EKG consistent with afib with RVR so he was referred to the ED.
He continues to deny any symptoms, no sensation of palpitations,
chest pain, shortness of breath, lightheadedness or dizziness.
He does report that he has had a new cough, productive of green
sputum over the past 2 days, no fevers or chills, no hemoptysis.
He denies any constipation, diarrhea, abdominal pain. He does
have chronic headaches. He states he is compliant with his
medications and he has a nurse that gives him his meds BID.
.
In the ED initial VS were 98.3 128 139/98 16 98% HR ranged from
125-130 in ED, received metoprolol IV 5 mg x 3 with brief
improvement in his heart rate to ___. CTA chest done for concern
for PE given d-dimer 1162, no PE but did show multifocal PNA. Pt
received azithro and ceftriaxone and admitted for management of
PNA and afib.
.
On the floor, pt has no complaints. He states he is feeling
fine, but overall poor historian.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-H/O LYMPHOMA: large cell probably T cell in jejunum s/p 6 mo
?chemo rx, CT abd WNLs in ___
-SMALL BOWEL OBSTRUCTION: thought to be secondary to lymphoma
-BACK PAIN: s/p 3 back operations last being in ___
-PSYCHOSIS: refuses to acknowledge, brief psych hospitalization
for manic episode ___
-HYPERTENSION
-GASTROESOPHAGEAL REFLUX
-HEADACHES
-URINARY FREQUENCY
-CATARACTS s/p surgical resection
-Fatty liver disease first noted in ___ with mild
transaminitis
-Type 2 DIABETES MELLITUS
-EXERTIONAL DYSPNEA
-ACTINIC KERATOSIS
-Likely drug induced PARKINSONISM
-MYOCARDIAL INFARCTION: documented in ___ at ___ with
presenting symptoms of N/V with EKG significant for an NSTEMI
and positive cardiac enzymes, subsequent ECHO WNLs, EF=60%
Social History:
___
Family History:
No cardiovascular disease other than HTN.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 98.5 BP: 136/101 P: 77 R: 18 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at right mid lung field, left lung ronchorous
with decreased breath sounds at base, no wheezes, rales
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM:
.
VITALS: 98.3 97.9 140/92 66-116 (104) 20 96% RA
I/Os: 910 | 740 FSG: 121
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Mucous membranes
dry without plaques or exudate.
NECK: supple.
___: Irregularly irregular rate and rhythm, without murmurs,
rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally with faint
inspiratory dry crackles at bases. No wheezing, rhonchi.
ABD: well-healed midline scar. Soft, non-tender, non-distended,
with normoactive bowel sounds.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: Evidence of cognitive impairment. Alert and oriented x 3.
Pertinent Results:
ADMISSION LABS:
.
___ 12:33PM BLOOD WBC-7.1 RBC-4.36* Hgb-12.0* Hct-35.8*
MCV-82 MCH-27.6 MCHC-33.6 RDW-14.6 Plt ___
___ 12:33PM BLOOD Neuts-76.1* Lymphs-15.1* Monos-5.9
Eos-2.6 Baso-0.4
___ 12:33PM BLOOD ___ PTT-31.2 ___
___ 12:33PM BLOOD Glucose-174* UreaN-17 Creat-0.9 Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 12:33PM BLOOD cTropnT-0.02*
___ 12:33PM BLOOD Calcium-7.9* Phos-2.7 Mg-1.3*
___ 02:25PM BLOOD D-Dimer-1162*
___ 12:33PM BLOOD TSH-2.4
___ 06:34PM BLOOD Lactate-1.6
.
DISCHARGE LABS:
.
___ 07:55AM BLOOD WBC-7.6 RBC-4.48* Hgb-12.0* Hct-37.5*
MCV-84 MCH-26.8* MCHC-32.0 RDW-14.8 Plt ___
___ 07:55AM BLOOD ___ PTT-51.0* ___
___ 07:55AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-135
K-4.5 Cl-101 HCO3-20* AnGap-19
___ 07:55AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6
.
URINALYSIS: clear, negative for ___, negative for Nitr, no
protein
.
MICROBIOLOGY DATA:
___ Blood cultures (x 2) - pending
___ Sputum culture - test cancelled, poor sample
.
IMAGING:
___ CHEST (PA & LAT) - Frontal and lateral views of the chest
were obtained. There are low lung volumes. Bibasilar opacities
are seen, which could be due to atelectasis, infection, or
aspiration. The cardiac and mediastinal silhouettes are
unremarkable. The hila are similar in appearance as compared to
___.
.
___ CTA CHEST W&W/O C&RECON - Nodular ground-glass opacities
in the right lung and left lower lobe with mild mediastinal
lymphadenopathy, consistent with multifocal pneumonia. Follow
up imaging is recommended after treatment to ensure resolution.
No pulmonary embolism. Mild pulmonary edema. 1.2 cm hypodense
nodule in the left lobe of the thyroid, which may be evaluated
further with thyroid ultrasound if clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. GlipiZIDE 5 mg PO DAILY
5. HydrALAzine 25 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 40 mEq PO DAILY
10. ammonium lactate *NF* 12 % Topical daily
to dry areas of legs
11. celecoxib *NF* 200 mg Oral daily:PRN pain
12. Mirtazapine 7.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. HydrALAzine 25 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Potassium Chloride 40 mEq PO DAILY
Hold for K > 5
8. ammonium lactate *NF* 12 % Topical daily
9. GlipiZIDE 5 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Mirtazapine 7.5 mg PO DAILY
12. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl 240 mg 1 capsule, extended release(s) by mouth
DAILY Disp #*30 Capsule Refills:*0
13. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
14. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 60 mg/0.6 mL 60 mg SC EVERY 12 HOURS Disp #*14
Syringe Refills:*0
15. Levofloxacin 750 mg PO DAILY Duration: 6 Days
started ___, ending ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth DAILY Disp #*6
Tablet Refills:*0
16. Outpatient Lab Work
Please check ___ in 2-days. Have results faxed to:
___. MD at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Paroxysmal atrial fibrillation, with rapid ventricular
response
2. Healthcare-associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: AP and lateral views of the chest.
CLINICAL INFORMATION: ___, recent hospitalization, tachycardia.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. There are
low lung volumes. Bibasilar opacities are seen, which could be due to
atelectasis, infection, or aspiration. The cardiac and mediastinal
silhouettes are unremarkable. The hila are similar in appearance as compared
to ___.
IMPRESSION: Low lung volumes. Bibasilar opacities could be due to infection,
aspiration and/or atelectasis.
Radiology Report
INDICATION: Palpitations and tachycardia.
COMPARISON: CT torso, ___, CT abdomen and pelvis, ___,
chest x-ray ___.
TECHNIQUE: Contiguous axial MDCT images were taken through the chest in
arterial phase after administration of 100 cc of Omnipaque intravenous
contrast material. Coronal and sagittal reformats as well as maximum
intensity projection oblique images were also examined.
FINDINGS: There is a 1.2 cm hypodensity in the left lobe of the thyroid.
There are ___ nodules in the right upper, right middle and right lower
lobes with hazy consolidation. There is also hazy consolidation at the left
lower lobe and left perifissural area. Mild, likely reactive, mediastinal
lymphadenopathy is present. These findings are consistent with a multifocal
pneumonia. There is mild septal thickening, concerning for mild pulmonary
edema. The central airways are patent.
CTA: The aorta and pulmonary vasculature are well opacified. The aorta
maintains a normal contour without any evidence of acute aortic syndrome. The
heart is normal in size without pericardial effusion. There is no pulmonary
embolism in main, right, left, lobar or subsegmental pulmonary arteries.
The imaged portions of the upper abdomen are unremarkable. There is no
suspicious lesion in the visualized osseous structures.
IMPRESSION:
1. Nodular ground-glass opacities in the right lung and left lower lobe with
mild mediastinal lymphadenopathy, consistent with multifocal pneumonia. Follow
up CXR is recommended after treatment to ensure resolution.
2. No pulmonary embolism.
3. Mild pulmonary edema.
4. 1.2 cm hypodense nodule in the left lobe of the thyroid, which may be
evaluated further with thyroid ultrasound if clinically indicated.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Tachycardia
Diagnosed with HEART FAILURE NOS, ATRIAL FLUTTER
temperature: 98.3
heartrate: 128.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 98.0
level of pain: 0
level of acuity: 2.0 | IMPRESSION: ___ with PMH significant for history of large T-cell
jejunal lymphoma (completed chemotherapy, complicated by SBO),
chronic paranoid schizophrenia, ___ disease, HTN, HLD,
GERD, non-insulin dependent diabetes mellitus, CAD (history of
NSTEMI) who presents with presumed new-onset atrial fibrillation
and concern for multifocal pulmonary infection.
.
# Paroxysmal atrial fibrillation vs. atrial flutter: Evidence of
increasing heart rate noted by ___ on ___ (118-130 bpm) with
PCP visit on ___ with HR that appeared NSR in the 120s. ECG
from ___ appears sinus. No prior history of A.fib reported.
Suspect atypical rhythm has been present greater than 48-hours
prior to admission. Patient denies lightheadedness, dizziness or
palpitations. No history of thyroid disease and normal TSH.
Admitted with A.fib with RVR to the 130 bpm range. No prior
anticoagulation (or ASA given prior GI bleeding concerns).
Etiology unclear, but patient has history of CAD, HTN which are
risk factors. Unlikely a rhythm of ischemia (cardiac biomarker
reassuring on admission, ECG without ischemia). He was monitored
on telemetry and he was maintained on oral Diltiazem and oral
metoprolol with adequate rate control. We deferred rhythm
control at this point; unlikely to benefit from cardioversion
given duration. As an outpatient, one could consider
TEE/cardioverion vs. attempt at chemical cardioversion. Given
evidence of intermittent regularity and possible ___
benefit from ablation in the future? We opted initiate
anticoagultaion given his CHADS2 score of 3 after discussion
with his home nursing staff. He was started on Lovenox 70 mg SC
Q12 hours with Coumadin 5 mg daily for bridging. At discharge,
his INR was 3.1 and thus we held his dose for ___. He was
provided with a lab slip to have his INR redrawn in 2-days and
his PCP ___ further determine ongoing Coumadin dosing. A TTE
was performed and demonstrated LVEF 40% and some rate-related
cardiomyopathy changes.
.
# Multifocal pneumonia: Reports 2-days of minimally productive
cough with yellow-whitish phlegm on admission. Denies dyspnea or
fevers. CT imaging of the chest revealed area of right greater
than left patchy opacification concerning for
healthcare-associated PNA vs. aspiration vs. atelectasis. He did
not require supplemental oxygen. He was initially covered with
Vancomycin, Cefepime and Metronidazole given concern for HCAP
vs. aspiration (started ___ but he was then transitioned to
oral Levofloxacin with good effect. Speech and swallow evaluated
him and felt there were no concerns for frank aspiration. A
sputum culture was attempted, but was difficult to obtain.
.
# Hypertension, essential: Home regimen includes CCB,
hydralazine, ACEI and beta-blocker. BP controlled at recent PCP
___. Continued home regimen.
.
# Coronary artery disease: History of NSTEMI in ___ (seen at
___). Treated conservatively with medical management, no report
of cardiac catheterization. No active chest pain. EKG without
ischemic. No ASA. Anticoagulated, as above. Continued statin.
.
# History of small bowel lymphoma: Recent admission for partial
high-grade SBO that improved with conservative management,
occurred at the anastomotic suture of his prior resection for
small bowel lymphoma. Also had received post-op radiation
treatment. On admission, passing flatus and having BMs.
Tolerating diet and without N/V. Benign abdominal exam. Will
need outpatient oncology ___.
.
# DMII: Glipizide held and patient started on HISS for now.
.
# HLD: Continue atorvastatin.
# Chronic paranoid schizophrenia: At baseline and well
controlled. Patient does not endorse any HI/SI or paranoid
thoughts. Not currently requiring anti-psychotics.
.
# ___ disease: continue home sinemet dosing.
.
# Incidental thyroid nodule: Noted incidentally on CT scan. TSH
2.4 this admission. Benign exam. Outpatient thyroid ultrasound.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
___ brain biopsy and EVD placement, Dr. ___
___ VP shunt placement, Dr ___
___ of Present Illness:
Patient presents to ED with 2 wks of headaches with nausea and
vomiting. Also unsteady gait and persistent double vision.
Companion states that she has
also been forgetful and not herself.
Past Medical History:
depression
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
: T:98.1 BP:130/87 HR:82 R:18 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm and minimally reactive EOMs: intact b/l
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place and year, but not month.
Cranial Nerves:
I: Not tested
II: Pupils equally round and minimally reactive to light. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: finger-nose-finger revealed some delay
bilaterally,
rapid alternating movements normal
ON DISCHARGE:
Gen: NAD
HEENT: no OP lesions, R frontal/parietal incision, with dried
blood otherwise well healed sutures intact w/ drainage,
partially shaved head. EOMI
PULM: CTAB
CV: rrr no m/r/g
Abd: Soft, nontender, nondistended.
___: no asterixis, no ___ edema or rash
Neuro: Oriented, drowsy but arouses to voice, EOMI, ___, bilat
horiz 2 beat nystagmus, face symmetric, no tongue deviation,
strength ___, sensation intact to light touch, visual fields
full to confrontation, FTN remains delayed but no dysmetria,
gait slow but steady w/ walker
Pertinent Results:
___ CTA HEAD ___ C & RECONS:
1. Interval placement of right frontal approach ventriculostomy
catheter with minimal interval decrease in the size of the
ventricles. Stable
transependymal flow of CSF.
2. Ill-defined heterogeneous pineal gland mass. Possible
differential
diagnosis includes germinoma versus pineoblastoma.
3. Prominent venous structures are identified from the mass
extending to
adjacent venous sinuses. No enlarged arterial structures are
seen.
___ CT STEREOTAXIS W/ CONTRAST:
1. Unchanged positioning of the ventriculostomy catheter, with
interval
decrease in the size of the lateral and third ventricles.
2. Large irregularly enhancing mass within the region of pineal
gland, causing effacement of the quadrigeminal plate cistern.
___ CT HEAD W/O CONTRAST:
1. Marked decreased size of the lateral ventricles as well as
decreased
effacement of the quadrigeminal plate cistern compared to the
prior
examination. Transependymal flow of CSF has also greatly
improved.
2. New small hyperdensity in third ventricle suggestive of small
intraventricular hemorrhage.
3. No evidence of acute infarction.
4. Ill-defined heterogeneous pineal gland mass is stable in
size.
___ MR ___ W/O CONTRAST; MR ___ &W/O
CONTRAST; MR ___ & W/O CONTRAST:
1. Heterogeneous high signal on axial T1 postcontrast imaging
within the
cervical and thoracic spine with more focal nodular high signal
at the C2-C3 and T8 levels, as described. These areas of high
signal are not seen on the sagittal T1 post-contrast sequence or
precontrast sequences. Given history of pineal mass, these
findings could represent subarachnoid seeding. Recommend
correlation with CSF analysis.
2. Mild degenerative changes of the cervical spine.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
4:17 ___
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
___ CXR
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia.
___ CT HEAD W/O CONTRAST
1. Hypodensity in the region of previously seen tumor as well as
in the
midline involving the genu and anterior portion of corpus
callosum could be
related to ischemic changes . Further evaluation with MRI of
the brain is
recommended.
2. The ventricular size is decreased compared to the prior
study.
3. There is redistribution of blood products in the third
ventricle but no
definite new hemorrhage seen.
___ MRI BRAIN
IMPRESSION:
1. The ventricles appear slit-like, similar to the most recent
CT from ___, but decreased compared to ___. VP
shunt catheter position is stable.
2. The large peripherally enhancing midline mass centered in the
pineal region demonstrates marked enlargement of its central
nonenhancing portion compared to the preoperative MRI from ___. The mass is now overall larger, extending
further anteriorly. The expanded central nonenhancing portion
appears heterogeneous, with complex fluid and small amount of
blood. The enlargement is most likely secondary to decreased
intracranial pressure and
associated fluid shifts after relief of hydrocephalus.
3. Unchanged mild contrast enhancement along the right superior
cerebellar
folia compared to the preoperative MRI, suggesting tumor
infiltration.
4. Linear blood products and contrast enhancement along the
biopsy track
through the right parietal and occipital parenchyma. The
contrast enhancement
is presumably reactive, but should be reassessed on follow up.
5. No evidence for an acute infarction.
Medications on Admission:
prozac
Discharge Medications:
1. Rolling Walker
Please dispense one rolling walker
Diagnosis: Gait unsteadiness secondary to brain mass
Prognosis: Poor
___: ___ weeks
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Dexamethasone 8 mg PO Q12H
take at 8am and again at 2 or 4pm
RX *dexamethasone 4 mg 2 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*1
4. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
take first
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID prn Disp
#*30 Tablet Refills:*1
6. Senna 17.2 mg PO BID:PRN constipation
take second
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*20 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Glioblastoma
Hydrocephalus
Diplopia
Cerebral edema
Discharge Condition:
Mental Status: Confused sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ year old woman with new pineal mass // Interval changes
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.0 s, 20.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
1,060.0 mGy-cm.
2) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 63.9 mGy (Head) DLP =
31.9 mGy-cm.
3) Spiral Acquisition 6.9 s, 22.3 cm; CTDIvol = 30.7 mGy (Head) DLP = 686.4
mGy-cm.
Total DLP (Head) = 1,778 mGy-cm.
COMPARISON: Outside head MRI from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is interval placement of right frontal approach ventriculoperitoneal
shunt catheter with its tip near the septum pellucidum in the frontal horn of
right lateral ventricle. There is associated new right frontal convexity
pneumocephalus. There is minimal interval decrease in the size of the
ventricles now measuring 3.6 cm, previously 3.8 cm. There is stable
hypodensities in the periventricular white matter in keeping with
transependymal flow of CSF.
There is an ill-defined hypo enhancing lesion in the region of the pineal
gland measuring approximately 2.9 x 4.1 cm causing effacement of the
quadrigeminal plate cistern corresponding to the previously seen
heterogeneously enhancing pineal mass.
There is no evidence of infarction or hemorrhage. No midline shift is seen.
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 with no evidence of stenosis,occlusion or aneurysm. The dural
venous sinuses are patent. There are several prominent vascular structures
likely veins (601 B: 16) extending from the mass to the adjacent venous
sinuses.
IMPRESSION:
1. Interval placement of right frontal approach ventriculostomy catheter with
minimal interval decrease in the size of the ventricles. Stable
transependymal flow of CSF.
2. Ill-defined heterogeneous pineal gland mass. Possible differential
diagnosis includes germinoma versus pineoblastoma.
3. Prominent venous structures are identified from the mass extending to
adjacent venous sinuses. No enlarged arterial structures are seen.
Radiology Report
EXAMINATION: CT STEREOTAXIS W/ CONTRAST
INDICATION: ___ year old woman with pineal tumor, pre-biopsy // CT
stereotaxis w/ frame on prior to OR
TECHNIQUE: Contiguous axial images of the brain were obtained after the
uneventful administration of Omnipaque intravenous contrast. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
COMPARISON: CTA Head within without contrast dated ___.
MRI from outside hospital dated ___.
FINDINGS:
Examination was performed with a stereotactic halo in place. There is a right
transfrontal approach ventriculostomy catheter, which is unchanged in
positioning and terminates in the frontal horn of the right lateral ventricle.
The lateral and third ventricles appear smaller, now measuring approximately
2.8 cm compared to 3.6 cm on the prior exam. Decreased transependymal flow of
CSF is noted. There is stable postoperative pneumocephalus within the right
frontal convexity.
Again visualized is the large irregularly enhancing mass within the region of
the pineal gland measuring approximately 2.9 x 4.1 cm causing effacement of
the quadrigeminal plate cistern. There is no evidence of fracture,
infarction, or hemorrhage.
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. Unchanged positioning of the ventriculostomy catheter, with interval
decrease in the size of the lateral and third ventricles.
2. Large irregularly enhancing mass within the region of pineal gland, causing
effacement of the quadrigeminal plate cistern.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with brain tumor status post stereotactic brain
biopsy. Evaluate postop changes.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: ___ head CTA.
___ outside contrast brain MRI.
FINDINGS:
Right frontal approach ventriculostomy shunt catheter is unchanged in
position. Minimal pneumocephalus along the right frontal convexity is
decreased from ___. The ventricles are decreased in size from ___. Periventricular hypodensities are less apparent on the current
examination consistent with significantly decreased transependymal flow of
CSF. New small hyperdensity is noted within the third ventricle (see 03:14).
As before in ill-defined hypoenhancing lesion in the region of the pineal
gland is unchanged in size in shows persistent effacement of the quadrigeminal
plate cistern, however the degree of effacement has decreased from the prior
examination.
There is no evidence of acute hemorrhage or infarction. No midline shift is
identified.
The visualized portion of the paranasal sinuses, mastoid air cells and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Marked decreased size of the lateral ventricles as well as decreased
effacement of the quadrigeminal plate cistern compared to the prior
examination. Transependymal flow of CSF has also greatly improved.
2. New small hyperdensity in third ventricle suggestive of small
intraventricular hemorrhage.
3. No evidence of acute infarction.
4. Ill-defined heterogeneous pineal gland mass is stable in size.
NOTIFICATION: The findings were discussed by Dr. ___ With Dr.
___ on the telephoneon ___ at 10:09 ___, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MRI of the cervical thoracic and lumbar spine with without
contrast. MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ female with 2 weeks of headache, nausea, vomiting and
unsteadiness with recent brain MRI demonstrating pineal mass. Evaluate for
spinal lesions.
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 9 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: None.
FINDINGS:
Study is moderately degraded by motion. Within these confines:
CERVICAL SPINE:
There is normal cervical alignment. The vertebral body heights are preserved.
The marrow signal is unremarkable. The intervertebral discs demonstrate
normal signal and height. There small central disc protrusions at C4-C5,
C5-C6, and C6-C7 causing mild spinal canal narrowing without significant
neural foraminal stenosis. There is a right C7-T1 foraminal perineural cyst
(11:33). The cervical cord demonstrates normal signal morphology. The
paravertebral soft tissues are unremarkable.
On axial T1 postcontrast imaging there is heterogeneous T1 hyperintensity
within the subarachnoid space, some which appears more focal such is in the
right ventral thecal sac at the C2-C3 level (21:13), with focal enhancement
measuring 3 mm. These areas of high signal are not seen on sagittal T1
postcontrast or precontrast imaging.
THORACIC SPINE:
There is normal thoracic alignment. The vertebral body heights are preserved.
The marrow signal is unremarkable. There intervertebral discs demonstrate
normal signal height. There is no significant neural foramina or spinal canal
stenosis. The thoracic cord demonstrates normal signal morphology. There is
no abnormal postcontrast enhancement. The paravertebral soft tissues are
unremarkable.
On axial T1 postcontrast imaging there is heterogeneous T1 hyperintensity
within the subarachnoid space, some of which appears more focal such as at the
dorsal left lateral aspect of the thoracic cord at the T8 level (08:34) where
there is nodular high signal measuring 4 mm. This is not seen on the sagittal
T1 postcontrast ward noncontrast sequences.
LUMBAR SPINE:
There is normal lumbar alignment. The vertebral body heights are preserved.
The marrow signal is unremarkable. The intervertebral disc spaces demonstrate
normal signal height. There is no significant neural foraminal or spinal
canal stenosis. The conus terminates appropriately at the mid L1 level. The
cauda equina nerve roots demonstrate normal signal morphology. There is no
abnormal postcontrast enhancement. Paravertebral soft tissues are
unremarkable.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Heterogeneous high signal on axial postcontrast imaging within the cervical
and thoracic spine with more focal nodular high signal at the C2-C3 and T8
levels, as described with now all corresponding findings on sagittal
postcontrast imaging. While findings may be artifactual in nature,
subarachnoid tumor seeding is not excluded on the basis of this examination.
Consider correlation with CSF analysis and attention on followup imaging.
3. Mild degenerative changes of the cervical spine.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ___ with 2 wks of HA, nausea, vomiting and
unsteadiness. MRI revealed pineal mass. // pre op pre op
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with new VPS. postop scans. Please do at 2200.
// ___ year old woman with new VPS. postop scans. Please do at 2200.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT head without contrast dated ___, MR head dated ___
FINDINGS:
A right frontal approach ventriculoperitoneal shunt catheter is again noted,
with the tip terminating in unchanged position at the level of the foramen of
___. Expected postprocedural pneumocephalus is noted. Previously seen
hyperdensity within the third ventricle is less prominent on the current
examination, likely reflective resolving blood products. Again noted is an
ill-defined, hypodense lesion in the region of the pineal gland, demonstrating
persistent effacement of the quadrigeminal plate cistern. Small hyperdensity
within the right and left lateral ventricles appears to have been present on
prior examination as well (03:18).
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. Status post right ventriculoperitoneal shunt placement.
2. Evolving blood products within the third ventricle. Small persistent
hyperdensity within the right lateral ventricle.
3. The region of the pineal tumor the slightly hypodense on the current study.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with ___ with 2 wks of HA, nausea, vomiting and
unsteadiness. MRI revealed pineal mass // interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.0 cm; CTDIvol = 53.0 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: CT ___, MR head ___
FINDINGS:
A VP shunt terminates in the region of the foramen of ___. An ill-defined
hypodense lesion in midline at the site of previously seen pineal mass. The
hypodensity within the lesion is new since the earlier CT of ___
but unchanged from ___ and could be due to tumor necrosis or
infarction. There is also a hypodensity seen within the region of the corpus
callosum series 3, image 16 which although unchanged from the earlier
examination of ___ is better visualized on the current study and
extends superiorly in the midline. The ventricles are smaller than seen on
the previous study. A small amount of blood products are seen inferiorly in
the third ventricle which due to redistribution of previously seen blood
products . There is no definite new hemorrhage identified.
IMPRESSION:
1. Hypodensity in the region of previously seen tumor as well as in the
midline involving the genu and anterior portion of corpus callosum could be
related to ischemic changes . Further evaluation with MRI of the brain is
recommended.
2. The ventricular size is decreased compared to the prior study.
3. There is redistribution of blood products in the third ventricle but no
definite new hemorrhage seen.
RECOMMENDATION(S): MRI with gadolinium.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 4:45 ___, 3 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old woman with pineal mass status post stereotactic
biopsy on ___ and VP shunt placement on ___. Further
investigation is requested of new hypodensity in the region of the tumor and
in the ___ and anterior corpus callosum, seen on the ___ head
CT and concerning for ischemia.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 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: Postsurgical head CTs from ___.
Presurgical MRI of the head from ___ and CTA of the head ___.
FINDINGS:
The midline mass centered in the pineal region demonstrates thick, irregular,
and nodular peripheral enhancement, as seen previously. The central
nonenhancing portion of the mass has markedly expanded compared to the
preoperative MRI from ___. This causes interval enlargement of
the mass with increased anterior extension. The mass now measures 5.8 cm AP,
3.7 cm craniocaudad, and 4.8 cm transverse, images 9:125 and 10:13, compared
to 4.0 x 3.5 x 3.5 cm when measured in the same planes on ___.
The central nonenhancing portion of the mass is heterogeneous with
predominantly high signal on T2 weighted images. Its signal on precontrast T1
weighted images is lobe was higher than that of CSF. It demonstrates only
small foci of low signal intensity on gradient echo images, consistent with
small amount of blood products. The enhancing rim of the mass demonstrates
low signal on gradient echo images, consistent with blood products.
There is mild contrast enhancement along the right superior cerebellar folia,
similar to the preoperative MRI from ___, suggesting tumor
infiltration.
There is linear T1 hyperintensity, low signal on gradient echo images, and
contrast enhancement extending from the right posterior aspect of the pineal
region mass to the right parietal burr hole, consistent with blood and
probably reactive enhancement along the surgical biopsy track.
A right frontal approach ventriculostomy catheter is again seen in place with
its tip in the frontal horn of right lateral ventricle. The ventricles are
slit-like, unchanged compared to the most recent CT from ___, but
decreased compared to the ___ head CT obtained immediately
following VP shunt placement. There is persistent slight asymmetry in the
size of frontal horns of the lateral ventricles, right smaller than left.
There is no evidence for acute infarction on diffusion-weighted images. Major
flow voids of the circle of ___ appear grossly preserved.
___ cisterna magna is again noted, a normal variant.
There is mild mucosal thickening in left greater than right maxillary sinuses
and ethmoid air cells.
IMPRESSION:
1. The ventricles appear slit-like, similar to the most recent CT from ___, but decreased compared to ___. VP shunt catheter
position is stable.
2. The large peripherally enhancing midline mass centered in the pineal region
demonstrates marked enlargement of its central nonenhancing portion compared
to the preoperative MRI from ___. The mass is now overall larger,
extending further anteriorly. The expanded central nonenhancing portion
appears heterogeneous, with complex fluid and small amount of blood. The
enlargement is most likely secondary to decreased intracranial pressure and
associated fluid shifts after relief of hydrocephalus.
3. Unchanged mild contrast enhancement along the right superior cerebellar
folia compared to the preoperative MRI, suggesting tumor infiltration.
4. Linear blood products and contrast enhancement along the biopsy track
through the right parietal and occipital parenchyma. The contrast enhancement
is presumably reactive, but should be reassessed on follow up.
5. No evidence for an acute infarction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Headache, Ataxia, Abnormal CT
Diagnosed with Other hydrocephalus, Other specified endocrine disorders
temperature: 98.1
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ yr old female who presented to ___ with
complaints of headache and vision changes accompanied by
nausea/vomiting and unsteady gait and intermittent confusion.
MRI revealed pineal mass with significant hydrocephalus. Patient
was brought to the OR for EVD placement and post-operative
admitted to the ICU for close neuro monitoring. Post-operative,
patient remained neurologically intact with intermittent double
vision.
#Glioblastoma - pineal mass found on brain MRI on admission as
above. Brain biopsy ___ consistent with glioblastoma. mass was
unresectable, she initiated brain XRT, ___ of ___ started ___,
she will return on ___ to resume treatments in ___
clinic. Sutures will be removed in ___ clinic this
week. She will also f/u with Dr ___ in ___ clinic w/ plan
to initiate avastin and temodar. Port will be placed as
outpatient in anticipation of ongoing chemotherapy in near
future. Ongoing neurologic deficits include intermittent
diplopia due to compression of tectum and word finding
difficulty. She is ambulatory with a walker. She declined home
___ and will start outpatient ___.
#Cerebral edema - ___ above, was started on dexamethasone, will
cont 8mg BID on discharge to be adjusted by rad onc or
neuro-onc. Also to be determined need for PCP ___ by ___
providers, if able to wean steroids quickly will not start
Bactrim.
#Hydrocephalus - Noted on admission head CT and brain MRI.
Patient underwent placement of EVD at time of brain biopsy by Dr
___ on ___, converted to VP shunt on ___ after decision made
that primary mass was not resectable. Delta Valve 1.5 placed the
procedure was well tolerated. She is no longer having
headaches. Follow-up with Dr ___ is being arranged.
# Hyponatremia - new finding on ___. Was started on salt tabs
per neurosurgery but had also been receiving IVF. she was also
started on Bactrim and steroids which can cause hyponatremia. No
acute changes in neuro symptoms, no headaches. salt tabs stopped
and Na remained stable, likely med related vs SIADH. Na remains
130 at time of discharge no further intervention indicated.
# Proteus UTI - received 3 days CTX. Also then initiated
Bactrim ___ after pt reported urgency however UA normal at that
time and repeat Cx negative. Bactrim stopped.
# Leukocytosis - likely due to steroids pt afebrile and no signs
systemic infxn |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Iodine-Iodine Containing / Aspirin / Epinephrine /
Clindamycin / Oxcarbazepine / Dilaudid / Lumigan / Alphagan P
Attending: ___.
Chief Complaint:
breakthrough seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ LH F with h/o complex migraines and
migrainous aura without headache vs. partial complex seizure
disorder (on gabapentin monotherapy w bitemporal discharges on
EEG), breast cancer s/p resection and glaucoma who presents with
multiple events in the past 24 hrs concerning for breakthrough
seizures.
Last night, on 2 occasions patient awoke suddenly from sleep and
sat bolt upright (felt like she was being "pulled up" into
sitting position), with a sudden extreme fear sensation and
screaming. Also smelled something "unpleasant" at this time
which has difficulty describing, not a burning smell. The
episodes lasted ~10 seconds each, and were followed by feeling
of extreme fatigue. No frank LOC during events, although has
difficulty fully remembering them afterward. In the morning, she
had 2 more of the same spells while downstairs in her home. No
palpitations, nausea or rising sensation. No headache except for
occasional bifrontal pressure headache which she attributes to
sinuses. Has history of anxiety but felt very different from
this, no increased stressors at home. She called Dr.
___ recommended she come to the ED for neurology
evaluation and possible admission.
In the ED waiting room, she had another spell. Has also had an
episode of olfactory aura alone (no fear) since arriving in her
room, none witnessed by me. She now feels she is back to
baseline but her husband states she is "not herself" (he has
difficulty describing exactly what he means by this, but does
think she seems a little "slower" than usual).
In terms of factors lowering seizure threshold, 2 weeks ago was
recently treated for a sinus infection (presenting with facial
pain, nasal congestion and purulent discharge) two weeks ago but
has been having ear "fullness" and conjunctival injection since
then. She has recently started antibiotic ear drops for this and
is scheduled to see ENT this week. Denies fever, chills,
rhinorrhea, dysuria, nausea, diarrhea, cough, sputum. She has
been having "interrupted" sleep for past few nights but
otherwise sleeping well. Has not missed any doses of her
gabapentin.
Patient she first developed the above spells (sudden fear
sensation, screaming, olfactory aura) in ___ and was
admitted to the EMU for 5 days to capture events. Gabapentin was
weaned off during the admission. EEG showed occasional
bitemporal (L>R) slowing and L temporal sharps but no
epileptiform discharges or seizures. During hospitalization she
had an MRI brain which was unremarkable, and an LP with
paraneoplastic antibody panel and cytology which was all normal.
She was discharged home on increased Gabapentin dose, and has
remained seizure-free since then (until today).
She was also admitted to EMU in ___ for separate events
concerning for CPSz vs. migraine aura without headache. She has
a history of migraine headaches in her ___ with complex auras
(zig-zag lines, headache and confusion). In ___ she
developed new events: sense of something about to happen,
flashing lights, cloudy vision, visual field cut and
face/lips/arm numbness. She was started on Keppra (stopped
___ due to side effect of feeling sick and tired),
subsequently added clonazepam and gabapentin. Then added
Oxcarbazepine which gave her a rash. Was admitted to EMU from
___ where all AEDs were stopped to capture events. EEG
showed bitemporal sharp and spike epileptiform discharges, but
no seizures.
She was discharged on gabapentin monotherapy. Ultimate etiology
of these events was thought to be migraine aura without
headache.
EPILEPSY RISK FACTORS: She was hit in the head with a baseball
___ years ago, no LOC. Has a cousin with seizures, no other FHx
of epilepsy or neurologic problems. No history of meningitis or
encephalitis. Highest level of education was college.
PRIOR AED TRIALS: Keppra (felt sick and tired), Oxcarbazepine
(rash), Clonazepam
Neuro ROS: pt denies headache but her husband says she has daily
migraines; neither of them can exactly describe the headache
quality. Denies any recent migraine auras. +chronic tinnitus and
vertigo. Denies difficulties producing or comprehending speech.
Denies focal weakness, numbness, parasthesiae. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
General ROS: +daytime fatigue for at least 6 months. Denies
recent fever or chills (though chronically "chilly"). 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:
1. Neurologic - Migraines with aura, Seizures (partial complex,
likely temporal lobe), Vertigo (prior head injury ~ ___ years
prior to admission when hit by baseball w/o LOC, lasts seconds
to one minute, episodic)
2. Oncologic - Breast cancer (dx ~ ___
3. Endocrine - Osteopenia
4. Gastrointestinal - h/o indigestion and "gassy" symptoms
5. Cardiovasculasr - Mitral valve regurgitation
6. Psychiatric - Anxiety (intermittent)
7. Ophthalmologic - Glaucoma (bilateral), Cataract (s/p R
surgery, ___
Social History:
___
Family History:
Seizures (cousin). ___ cancer (family).
Physical Exam:
GENERAL EXAM:
- Vitals: 97.3 72 123/60 18 100% RA
- General: Awake, cooperative, NAD.
- HEENT: NC/AT. +conjunctival injection. Unable to complete
HEENT eval (pt in hall), no acute abnormalities per ED.
- 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.
NEURO EXAM:
- Mental Status: Awake and alert, oriented to person and place
but states date is ___ or ___. Able to
relate history without difficulty but has difficulty with
details of today's events and timeline of her prior episodes.
Attentive, able to name ___ backward without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Able to name
both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Able to register 3 objects
and recall ___ at 5 minutes ___ with categorical prompting, ___
with choices) which is stable from prior evals. Good knowledge
of current events. No evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to finger counting.
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 except mild wasting of EDBs bilaterally.
Normal tone throughout. No pronator drift. 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 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted. No dysmetria on FNF or HKS bilaterally.
- Gait: not tested
Pertinent Results:
ADMISSION LABS
___ 04:45PM GLUCOSE-92 UREA N-8 CREAT-0.6 SODIUM-134
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-11
___ 04:45PM estGFR-Using this
___ 04:45PM CALCIUM-9.0 PHOSPHATE-3.0# MAGNESIUM-1.7
___ 04:45PM WBC-5.6 RBC-4.01* HGB-12.5 HCT-36.4 MCV-91
MCH-31.1 MCHC-34.2 RDW-12.5
___ 04:45PM NEUTS-75.9* LYMPHS-17.1* MONOS-3.7 EOS-3.0
BASOS-0.3
___ 04:45PM PLT COUNT-153
___ 03:03PM LACTATE-1.3
___ 03:00PM ALT(SGPT)-17 AST(SGOT)-44* ALK PHOS-59 TOT
BILI-0.5
___ 03:00PM ALBUMIN-4.2
___ 03:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CXR ___
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 500 mg PO Q7:00 AM
2. Gabapentin 500 mg PO Q3:00 ___
3. Gabapentin 600 mg PO HS
4. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
5. travoprost 0.004 % ophthalmic daily
6. Atenolol 12.5 mg PO DAILY:PRN palpitations
7. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID
Discharge Medications:
1. Gabapentin 500 mg PO QAM
2. travoprost 0.004 % OPHTHALMIC DAILY
3. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
4. Neomycin-Polymyxin-HC Otic Susp 4 DROP BOTH EARS TID
5. Gabapentin 500 mg PO Q3:00 ___
6. Atenolol 12.5 mg PO DAILY:PRN palpitations
7. Gabapentin 600 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
partial complex seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no focal abnormalities
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with seizure. Evaluation for pneumonia.
COMPARISON: Comparison is made to radiographs of the chest from ___.
FINDINGS: PA and lateral views of the chest demonstrates the lungs are well
expanded and clear. The cardiomediastinal silhouette is unremarkable.
Surgical clips are again seen in the right breast. There is no pleural
effusion, pulmonary edema, pneumothorax or focal consolidation concerning for
pneumonia.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SEIZURE
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY, ALTERED MENTAL STATUS
temperature: 97.3
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ LH F with h/o complex migraines
and migrainous aura without headache vs. partial complex seizure
disorder (on gabapentin monotherapy w bitemporal discharges on
EEG), breast cancer s/p resection and glaucoma who presents with
multiple events in the past 24 hrs concerning for breakthrough
seizures. Describes these as sudden sensation of being "pulled
forward", extreme fear and screaming, and unpleasant smell that
last 10 seconds and are followed by fatigue. Has had total of 5
spells since last night and one olfactory aura in ED. Of note,
recently had sinusitis and has ongoing ear fullness and
conjunctival injection, which could be a risk factor for
increased seizure frequency.
She was admitted to the EMU for EEG LTM with hopes of capturing
an event. However, she had no further events upon admission, so
rather than waiting to have telemetry started, the patient asked
to leave with plans for elective admission in the future. She
was counseled that she remained at risk of having futher seizure
events at home, and she should continue to practice seizure
precautions, and return to the ED if she felt unsafe. Gabapentin
continued at home dose
TRANSITIONAL ISSUES
- F/U with neurology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nitrate Analogues
Attending: ___.
Chief Complaint:
Hypoglycemia, encephalopathy
Major Surgical or Invasive Procedure:
Dobhoff placement and removal x 2
History of Present Illness:
Note: History obtained from patient's husband through an
interpreter, the ___ medical record, and records from her
rehabilitation center-- ___ Health and Rehab]
Ms. ___ is a ___ ___ speaking woman presenting from rehab
on ___ with confusion and restlessness overnight, found at
rehab to be hypoglycemic, hypotensive, and possible PNA.
On the morning of ___ around 6am Ms. ___ was found to be
unable to take her scheduled medications. She had been noted to
be goaining and restless in bed overnight. FSBG at that time was
48 and hypotensive to 76/40. She was given glucagon with
improvement in BS to 112 and BP to 129/67. Transferred to ___
ER for further evaluation.
She had a recent hospitalization (___) for
influenza A, COPD, acute-on-chronic ___ exacerbation, UTI,
hypernatremia, acute-on-chronic CKD, and NSTEMI type 2.
In the ED, initial vitals were: 95.7 61 157/86 14 99% at
triage, her HR remained between ___ and her blood pressure
downtrended into SBP's of 100's. She was noted to have a ___
as low as 40. Her O2 sat was initially 98-100% on RA, but
downtrended to 90% and she required 2L NC. She was given a total
of 4L of IVF (NS, D5NS, and LR) as well as dextrose x 2 for
hypoglycemia. She was given cefepime and vanc for PNA seen on
CXR. She was noted to have low urine output prior to admission
and bolused 500 cc.
On the floor, she remains lethargic and is unable to participate
in the exam to endorse or deny symptoms.
Past Medical History:
Primary Biliary Cirrhosis
Chronic itching
iron deficiency anemia
Diabetes mellitus, type 2, poorly controlled, last HbA1c 9.0
___
Atrial fibrillation, on coumadin
Coronary artery disease s/p stent to the RCA ___.
systolic heart failure (LVEF 60-65%, no comment on diastolic
function on ___
Hypertension.
Hypercholesterolemia.
Seizures
___ disease
Hx. PUD and gastritis
Hx. abnormal pap smears
Status post bilateral total knee replacement.
Low back pain
Chronic kidney disease with baseline creatinine 1.3-1.9
Social History:
___
Family History:
Brother with DM. No CAD or COPD.
Physical Exam:
Admission physical
===================================
Vitals: 98.5, 146/69, 74, 18, 100% on 2L NC
General: Lethargic, lying in bed in NAD
HEENT: Sclera anicteric, MM mildly dry, oropharynx clear, PERRL
Neck: Supple, JVP difficult to assess to due neck size
CV: irregilarly irregular rhythm, normal rate, normal S1 + S2,
no murmurs, rubs, gallops
Lungs: Diffuse moderate wheezing throughout all lung fields. No
rales or rhonchi
Abdomen: Distended, obese, Soft, non-tender, bowel sounds
present, unable to appreciate organomegaly, no rebound or
guarding
GU: foley in place draining yellow urine
Ext: Warm, well perfused, 2+ DP pulses. Clubbing noted in upper
and lower extremities.
Neuro: Somnolent, opens eyes and weakly squeezes hands when
verbally asked. Does not vocalize in response to questions,
easily falls asleep again. Can briefly sit up with assistance.
Discharge physical
====================================
DISCHARGE WEIGHT (STANDING, MID-DAY) = 79.9kg
Vitals: 98.4 82 134/51 20 95% on 1L ___ pain
I/O:
-- AM 8 hr: 0/large inc
-- yest 24 hr: 770/7505 + inc
General: Lying in bed, awake and alert. Oriented to person and
"Hospital, ___, not date or year.
HEENT: conjunctiva with trace resolving hemorrhages, minor left
erythema. MM very dry, oropharynx clear, PERRL, EOMI
Neck: Supple, JVP WNL
CV: irregularly irregular rhythm, normal rate, normal S1 + S2,
no murmurs, rubs, gallops.
Lungs: CTAB no W/R/R
Abdomen: Distended, obese, Soft, non-tender to palpation in all
quadrants, bowel sounds present
GU: seen prior to second baldder scan and foley placement, at
that time no foley in place
Ext: Warm, well perfused. Clubbing noted in upper and lower
nailbeds. No peripheral edema in lower extremities,
hips/dependent portions. Knees notable for bilateral knee
replacement scars.
Neuro: A&O x 2, can state name, hospital, and ___. Not year
or name of hospital. EOMI, tongue midline. Moves all four
extremities purposefully and follows commands.
Pertinent Results:
Admission labs:
___ 10:09AM BLOOD WBC-9.9 RBC-4.58 Hgb-10.3* Hct-38.2
MCV-83 MCH-22.5* MCHC-26.9* RDW-25.2* Plt ___
___ 10:09AM BLOOD ___ PTT-38.7* ___
___ 10:09AM BLOOD Glucose-38* UreaN-35* Creat-1.7* Na-143
K-5.1 Cl-104 HCO3-30 AnGap-14
___ 10:09AM BLOOD ALT-7 AST-51* AlkPhos-113* TotBili-0.4
___ 07:40AM BLOOD ___
___ 10:09AM BLOOD Albumin-3.2* Calcium-9.2 Phos-5.1*#
Mg-2.3
Important labs:
___ 08:05AM BLOOD ___ 08:05AM BLOOD Ret Man-1.4
___ 06:50AM BLOOD cTropnT-0.02*
___ 02:55PM BLOOD cTropnT-0.02*
___ 08:05AM BLOOD calTIBC-333 VitB12-1233* Folate-14.6
___ Ferritn-50 TRF-256
___ 05:55AM BLOOD TSH-12*
___ 08:15AM BLOOD T4-6.2 T3-95
Discharge Labs:
___ 07:50AM BLOOD WBC-6.2 RBC-4.03* Hgb-9.4* Hct-33.7*
MCV-84 MCH-23.4* MCHC-27.9* RDW-23.7* Plt Ct-72*
___ 07:50AM BLOOD ___ PTT-39.7* ___
___ 07:50AM BLOOD Glucose-93 UreaN-27* Creat-1.3* Na-143
K-3.4 Cl-96 HCO3-39* AnGap-11
___ 08:05AM BLOOD ALT-7 AST-25 LD(LDH)-381* AlkPhos-86
TotBili-0.5
___ 07:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8
___ 08:05AM BLOOD TotProt-6.5 Calcium-9.0 Phos-3.8 Mg-1.8
Iron-22*
___ 08:05AM BLOOD calTIBC-333 VitB12-1233* Folate-14.6
___ Ferritn-50 TRF-256
___ 08:15AM BLOOD T4-6.2 T3-95:
Micro:
___ 11:43 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ Blood cx negative
___ 10:37 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging:
___ EKG
Slight baseline artifact. Diminished limb lead QRS amplitude.
Atrial
fibrillation with a well-controlled ventricular rate.
Non-specific ST segment
flattening in lead I with T wave inversion in lead aVL.
Suggestion of
Q waves in leads III and aVF consistent with prior inferior
myocardial
infarction. Poor anterior R wave progression consistent with
prior anterior
myocardial infarction. Left axis deviation with left anterior
fascicular
block. Compared to the previous tracing of ___ the overall
ventricular
rate is slightly faster. T waves are more inverted in lead aVL.
Left
precordial electrode placement is clearly different. An ongoing
lateral
ischemic process cannot be excluded. Clinical correlation is
suggested.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is substantial
enlargement
of the cardiac silhouette with moderate pulmonary edema and
bilateral
effusions with compressive atelectasis at the bases.
___ PORTABLE CXR AP
FINDINGS:
AP portable upright view of the chest. Increased opacities in
the lower lungs raise concern for early pneumonia. There is a
small left pleural effusion. No overt evidence for an edema. No
pneumothorax. Patient is rotated to the left. Prominent
cardiomediastinal silhouette is stable. No acute bony
abnormalities.
IMPRESSION:
Increased opacities in the lower lungs raise concern for
pneumonia. Small left effusion.
___ NONCONTRAST HEAD CT
FINDINGS:
There is no evidence of hemorrhage, infarction, mass, edema, or
shift of normally midline structures. Mild prominence of the
ventricles and sulci likely relate to age related involutional
changes, unchanged from prior. There is minimal left maxillary
sinus mucosal thickening. Otherwise, the visualized paranasal
sinuses and mastoid air cells are clear. The patient is status
post bilateral lens removal. There is mild swelling of the soft
tissues along the
left periorbital region. There is no evidence of fracture.
IMPRESSION:
No evidence of acute intracranial process. Mild edema of the
left periorbital soft tissues. No evidence of fracture.
EKG: A fib, HR 86. Q waves in V1-V3, III, aVF and poor R wave
progression unchanged from prior from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Docusate Sodium 100 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Lactulose 30 mL PO BID
6. LeVETiracetam 500 mg PO BID
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Psyllium 1 PKT PO DAILY
10. Senna 8.6 mg PO QHS
11. Simvastatin 40 mg PO QPM
12. Tiotropium Bromide 1 CAP IH DAILY
13. Torsemide 60 mg PO DAILY
14. TraZODone 50 mg PO QHS
15. Ursodiol 600 mg PO BID
16. Zolpidem Tartrate 5 mg PO QHS
17. Acetaminophen 650 mg PO Q4H:PRN pain
18. Mylanta 30 ml oral QID PRN heartburn
19. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
20. Bisacodyl 10 mg PR QHS:PRN constipation
21. DiphenhydrAMINE 25 mg PO QHS:PRN severe itching
22. Fleet Enema ___AILY:PRN constipation
23. Milk of Magnesia 30 mL PO DAILY:PRN constipation
24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6hr:PRN SOB, dyspnea
25. TraMADOL (Ultram) 50 mg PO BID:PRN pain
26. TraZODone 25 mg PO QHS:PRN sleep, agitation
27. NovoLIN 70/30 (insulin NPH and regular human) 20 units
subcutaneous BID
28. 70/30 20 Units Breakfast
70/30 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
29. Warfarin Dose is Unknown PO DAILY16
30. loperamide 2 mg oral q2hr:PRN loose stool
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Docusate Sodium 100 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. LeVETiracetam 500 mg PO BID
10. Metoprolol Succinate XL 150 mg PO DAILY
11. Psyllium 1 PKT PO DAILY
12. Senna 8.6 mg PO QHS
13. Simvastatin 40 mg PO QPM
14. Tiotropium Bromide 1 CAP IH DAILY
15. Ursodiol 600 mg PO BID
16. Omeprazole 40 mg PO BID
17. QUEtiapine Fumarate 12.5 mg PO QHS
18. QUEtiapine Fumarate 12.5 mg PO DAILY:PRN agitation
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6hr:PRN SOB, dyspnea
20. TraMADOL (Ultram) 50 mg PO BID:PRN pain
21. Fleet Enema ___AILY:PRN constipation
22. Lactulose 30 mL PO BID
23. loperamide 2 mg oral q2hr:PRN loose stool
24. Milk of Magnesia 30 mL PO DAILY:PRN constipation
25. Mylanta 30 ml oral QID PRN heartburn
26. Warfarin 2 mg PO DAILY16
27. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID Duration: 5
Days
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
Primary:
# ___ Associated Pneumonia
# decompensated diastolic HF
# suspicion for Hypothyroidism
# Encephalopathy
# Hypernatremia
# Hypoglycemia/Type 2 Diabetes
# thrombocytopenia
# AF/anticoagulation
# Acute on Chronic Kidney Injury
# poor po intake
Secondary:
# Primary Biliary Cirrhosis
# chronic iron deficiency anemia
# COPD/asthma
# ___ Disease/Dementia
# Hypertension
# History of seizures
# ___ disease
# HLD
Discharge Condition:
Mental Status: Confused - most times (A&O x ___.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD, CHF, persistent O2 requirement //
interval change of effusion, other acute process interval change of
effusion, other acute process
IMPRESSION:
In comparison with the study of ___, there is substantial enlargement
of the cardiac silhouette with moderate pulmonary edema and bilateral
effusions with compressive atelectasis at the bases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with staged dobhoff placement // ___ dobhoff
placement XR ___ dobhoff placement XR
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
a Dobbhoff tube with its tip in the mid to upper stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p dobhoff placement // dobhoff placement
dobhoff placement
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
3 images are submitted, showing sequential progression of the esophageal
feeding tube with the wire stylet in place from the upper midline on image
labeled #1. , to the mid esophagus on #2, to the distal esophagus on # 3. .
Moderate to severe cardiomegaly is chronic. Mild pulmonary edema has changed
in distribution but not in overall severity since ___ accompanied by
stable come moderate bilateral pleural effusion right greater than left.
There is no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: DOBHOFF PLACEMENT
IMPRESSION:
In comparison with the earlier study of this date, the Dobbhoff tube now
extends well into the stomach.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIAB W MANIF NEC ADULT
temperature: 95.7
heartrate: 61.0
resprate: 14.0
o2sat: 99.0
sbp: 157.0
dbp: 86.0
level of pain: 13
level of acuity: 2.0 | ___ ___ presents from SNF with confusion and
restlessness overnight, found to be hypoglycemic and
hypotensive, with possible HCAP s/p treatment, course
complicated by decompensated heart failure, severe delirium,
poor PO, and thrombocytopenia.
ISSUES ACTIVE AT DISCHARGE
# thrombocytopenia: Gradually downtrending since admission,
nadired at 52 on ___, currently 72 at discharge. No clinical
evidence of bleeding and no H&H drop, so consumptive
thrombocytopenia unlikely. Liver and spleen appeared normal on
CT in ___ and LFTs were WNL. Etiology was not entirely clear.
She was seen by the hematology consult service, and an initial
work up was done. Could be due to iron deficiency, medication
effect (on cefepime ___, or other etiology. Very low
likelihood of HIT. Will need hematology follow up with Dr.
___.
# Suspicion for Hypothyroidism: TSH of 12, however in the
setting of a hospitalized patient with recent serious medical
illness this admission, utility of this TSH is less certain.
Her encephalopathy recovered prior to supplementation, so repeat
TSH in ___ week recommended to confirm diagnosis. She was not
started on supplementation.
# Encephalopathy: Initially was quite delerious with mental
status ranging from somnolent (responsive to pain) to agitated
(pulling IVs and dobhoffs) to baseline (A&O x ___ and pleasantly
chatty). For the ___ days prior to discharge, she was at
baseline and meaninfully involved in her ___, without any need
for chemical or medical restraints. Was possibly related to her
pneumonia, heart failure, dysynchronous day/night cycle, and
dobhoff. Keppra level was 34.4 (unclear whether peak/trough),
which was above the expected range for a 500mg BID dosing
schedule (trough RR is 3.1-10.0 mcg/mL and peak RR is 10.0-25.0
mcg/mL). However her mental status improved, so the dosing was
not changed. She is very easily oversedated by trazodone, which
we discontinued using during this hospitalization. Her Zolpidem
was also discontinued. Scheduled 12.5mg seroquel at night to aid
with establishing day/night routine.
# Hypoglycemia/Type 2 Diabetes: Her initial hypoglycemia prior
to presentation was likely related to HCAP, poor PO intake, and
insulin regimen. She was changed from 20 units of 70/30 BID
with ISS to 10 glargine qHS with sliding scale with no lows and
relative control ___ day prior to discharge was 99-215).
HgbA1c 9.5 in ___.
# AF/anticoagulation: Prior to admission was rate-controlled at
home on metoprolol sucinate 200mg daily, she was rate controlled
here with 150mg daily. CHADS2 score is 4, has never had CVA. On
warfarin, which was initially supratherapeutic on admission
(likely decreased PO intake). When she was on tube feeding, she
was subtherapeutic and on lovenox. She was therapeutic for 2
days prior to discharge. Warfarin dosing will need to be closely
followed while her PO intake is fluctuating.
# Nutrition/Concern about swallow: Mainly effected by mental
status, requiring dobhoff for medication and tubefeeds for
approximately 4 days. She was evaluated by nutrition when she
was at her baseline mental status prior to discharge and was
recommended for Aspiration precautions, nectar thick and puree,
small bites, and 1:1 observation for meals.
# Family meeting, Goals of ___: Had a family meeting with her
___, granddaughter, and ___. Reviewed her
condition and likely progressive course of her dementia.
Discussed that at times during this stay she required physical
restraints to prevent her from removing her dobhoff tube
multiple times. At this time, they had no changes to what they
believe she would want, but will continue to discuss what
interventions are within her goals of ___ with her PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine
Attending: ___
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ yo woman with PMH of pulmonary HTN and
right-sided HF, HTN, HLD, AF, PFO, valvular heart disease p/w
diarrhea.
Her symptoms began around ___ after taking macrobid for UTI.
At
that time she noted profuse watery diarrhea. She was admitted
___ and diagnosed with c diff. During that admission her
WBC was elevated to 22. She was discharged on high dose oral
vancomycin 500 mg q6hrs to complete a 14 day course. She
finished
the course ___ and shortly after again had increased diarrhea.
She returned to the ED ___ for evaluation. During this visit
stool samples were sent and she was given a week more of oral
vancomycin. Notably after discharge her c diff came back
negative. At home she continued to have diarrhea and increasing
weakness.
She called her PCP and said she was too weak to be seen. Her PCP
gave her ___ 4 week course of oral vancomycin. She began to feel
too weak to get out of bed and her son was worried she was
slightly confused. She also endorses poor PO intake. She denies
any fevers, chills, sick contacts. Denies any abdominal pain.
14 point ROS negative except per HPI
In the ED vitals on arrival were T 98.7, HR 80, BP 99/58, RR18,
O2Sat 95% RA. She was given 1L NS. Labs were checked which were
remarkable for Cr 1.7, Hgb 8.9, WBC 9.8, UA with only 2 wbc, INR
2.9. She was not given any medications. Her vitals on transfer
were T 97.5, HR 58, BP 108/55, RR16, O2Sat 93% 2L
Upon arrival to the floor, the patient feels tired and
frustrated
she has ongoing symptoms. Endorses the
story above. No new complaints.
Past Medical History:
=====================
1. Complex pulmonary hypertension: Diagnosed in ___
during hospitalization, right heart catheterization revealing RA
17, PCWP 19, mean PAP 33, 3.6 Woods units.
2. Right ventricular failure.
3. Paroxysmal atrial fibrillation.
4. Heart failure with preserved ejection fraction.
5. Prediabetes (hemoglobin A1c 6.3%).
6. Hypertension.
7. Obstructive sleep apnea, on CPAP.
8. PFO.
9. GERD.
10. Obesity.
11. Former tobacco use.
Social History:
___
Family History:
Family History: Father died at ___ of heart disease. Mother died
at ___ of heart disease, had a CABG and valve replacement prior.
7
siblings, 4 of whom passed away at older age. 4 children who are
healthy. No family history of hypertension, diabetes mellitus,
or
SCD.
Physical Exam:
ADMISSION EXAM:
General Appearance: pleasant, very pale, comfortable, no acute
distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: irregular, S1 and S2 wnl, soft systolic murmur
Gastrointestinal: obese, nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, right ankle with slight effusion,
bilateral varicose veins
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
DISCHARGE EXAM:
Gen: sitting up in bed, comfortable appearing
Eyes: no scleral icterus, EOMI
ENT: OP clear, MMM
Heart: RRR no mrg, elevated JVD
Lungs: mild crackles at bases, otherwise CTA bilaterally
Abd: soft nontender, normal bowel sounds
Ext: trace pitting edema b/l ___, wwp
Neuro: AOx3, moving all extremities
Psych: pleasant, appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-9.6 RBC-2.97* Hgb-8.9* Hct-27.6*
MCV-93 MCH-30.0 MCHC-32.2 RDW-16.1* RDWSD-54.7* Plt ___
___ 04:00PM BLOOD ___ PTT-71.4* ___
___ 04:00PM BLOOD ___ PTT-71.4* ___
___ 04:00PM BLOOD Glucose-117* UreaN-34* Creat-1.7* Na-138
K-5.0 Cl-98 HCO3-18* AnGap-22*
DISCHARGE LABS:
___ 04:00PM URINE MUCOUS-RARE*
___ 09:15AM BLOOD WBC-12.3* RBC-3.11* Hgb-8.8* Hct-28.7*
MCV-92 MCH-28.3 MCHC-30.7* RDW-16.1* RDWSD-54.7* Plt ___
___ 09:15AM BLOOD Glucose-143* UreaN-25* Creat-1.0 Na-142
K-3.8 Cl-100 HCO3-28 AnGap-14
___ 09:15AM BLOOD Calcium-8.7 Mg-2.1
CXR
No definite radiographic evidence for pneumonia. Mild pulmonary
vascular
congestion with bibasilar atelectasis.
CT Abd/Pelvis
1. No evidence of acute colitis or other acute abdominopelvic
abnormality.
2. Diverticulosis without evidence of diverticulitis
3. Cholelithiasis
4. Small bilateral pleural effusions with overlying atelectasis.
Superimposed
pneumonia would be hard to exclude in the proper clinical
context.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AcetaZOLamide 125 mg PO Q24H
2. Amiodarone 200 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lisinopril 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Phenelzine Sulfate 15 mg PO TID
8. Torsemide 20 mg PO EVERY OTHER DAY
9. Torsemide 10 mg PO EVERY OTHER DAY
10. Vitamin D 1000 UNIT PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Vancomycin Oral Liquid ___ mg PO Q6H
13. biotin 1 mg oral DAILY
14. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
15. Pantoprazole 20 mg PO Q24H
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. AcetaZOLamide 125 mg PO Q24H
4. Amiodarone 200 mg PO DAILY
5. biotin 1 mg oral DAILY
6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
7. Dabigatran Etexilate 150 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Lisinopril 10 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Pantoprazole 20 mg PO Q24H
13. Phenelzine Sulfate 15 mg PO TID
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-infectious diarrhea
Acute heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with weakness//pneumonia?
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Evaluation is slightly limited by patient rotation. Moderate to severe
cardiac enlargement is re-demonstrated, grossly unchanged. The aorta is
tortuous with mild atherosclerotic calcifications noted at the aortic arch.
Central mediastinal venous congestion is present. Mild pulmonary vascular
congestion is demonstrated with patchy atelectasis noted in the lung bases.
Lungs are hyperinflated with mild emphysematous changes re-demonstrated. No
focal consolidation, pleural effusion, or pneumothorax is detected. No acute
osseous abnormality is visualized.
IMPRESSION:
No definite radiographic evidence for pneumonia. Mild pulmonary vascular
congestion with bibasilar atelectasis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.1 s, 46.4 cm; CTDIvol = 20.1 mGy (Body) DLP = 919.1
mGy-cm.
Total DLP (Body) = 919 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions, right greater than
left with subjacent opacities which likely reflect atelectasis however
superimposed pneumonia would be hard to exclude. The visualized airways are
patent. There is a large hiatal hernia. Calcification of the mitral valve is
present. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. The previously seen enhancing lesion in the left hepatic lobe is not
visualized on this nonenhanced study. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder contains gallstones without
wall thickening or evidence of inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is a 1.3 cm calcified splenic artery
aneurysm, unchanged.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a large hiatal hernia. Otherwise the stomach is
unremarkable. Small bowel loops demonstrate normal caliber and wall thickness
throughout. There is extensive diverticulosis of the sigmoid and descending
colon without evidence of acute diverticulitis. No abnormal bowel wall
thickening or pericolonic inflammation to suggest active colitis. 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. Moderate to severe
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of acute colitis or other acute abdominopelvic abnormality.
2. Diverticulosis without evidence of diverticulitis
3. Cholelithiasis
4. Small bilateral pleural effusions with overlying atelectasis. Superimposed
pneumonia would be hard to exclude in the proper clinical context.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with Diarrhea, unspecified
temperature: 98.7
heartrate: 80.0
resprate: 18.0
o2sat: 95.0
sbp: 99.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female with past medical history of
complex pulmonary hypertension, paroxysmal atrial fibrillation,
diastolic CHF, OSA on CPAP, obesity, with recent admission
___ for Cdiff colitis admitted with persistent loose stool
and dyspnea on exertion, found to be volume overloaded
# Diarrhea
Patient presented with multiple bowel movements at home in
setting of prior hospital stay for Cdiff colitis. She had been
seen in ED with a negative Cdiff PCR but had been continued on
PO vancomycin anyways. On this admission, repeat Cdiff PCR was
negative. CT abd/pelvis did not show signs of colitis or other
acute GI abnormality. Diarrhea spontaneously resolved following
admission and returned to normal frequency. It is possible that
she had a viral enteritis that resolved around time of
presentation.
# Acute hypoxic respiratory failure
# Acute on Chronic Diastolic CHF
# ___ secondary to cardiorenal syndrome
Patient admitted with hypoxia, Cr 1.7 from baseline 1.0, as well
as weight of 190lbs from prevously recorded 180lbs during prior
admission. Patient was felt to have cardiorenal syndrome
secondary to acute dCHF. She was started on IV diuresis with
improvement in her weight and oxygenation. She was discharged
at her dry weight of 179-180lb and resumed on home torsemide
(dose increased from 20mg/10mg QOD to 20mg daily). She will
have ___ come for routine weight and BMP checks.
# Anemia
Patient admitted with Hgb 8.6 from 10.7 during recent prior
admission. Labs notable for absence of signs of hemolysis or
nutritional deficiency. She was guaiac negative without signs
of active bleeding. She did have a large bruise on her
posterior L shoulder and concern that her pradaxa may have
acheived supratherapeutic levels in setting of her ___ as below.
Her Hgb subsequently remained stable without worsening anemia.
It was felt that she may have had a missed bleed in the setting
of above pradaxa issues with possible bone suppression in
setting of her recent illnesses. Would consider outpatient
workup if anemia persists or worsens.
# UTI: pt found to have positive urine culture for pansesnitive
e.coli on admission. However, her UA was initially negative.
D/t worsening leukocytosis UA was rechecked and found to be
dirty on repeat. She was treated with 3 days of Bactrim for
uncomplicated cystitis.
# Paroxysmal Afib
As above, in setting of renal failure, Pradaxa was held
initially. It was then restarted once ___ resolved.
#HTN
Held lisinopril in setting of acute illness above. Restarted on
discharge.
#OSA
Continued acetazolamide
# Depression
Continued Phenelzine
# GERD
Continued PPI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
naproxen / Zoloft
Attending: ___
Chief Complaint:
Acute on chronic chest pain
Major Surgical or Invasive Procedure:
___ LP (___)
History of Present Illness:
HPI: ___ with hx of paranoid schizophrenia, NIDDM, recently
diagnosed stage IV lung cancer not yet undergoing treatment
presenting with acute on chronic chest pain. Pt was admitted to
___ ___ after presenting with chest pain, dyspnea,
confusion, and 40 lb weight loss. He was known at that time to
have a RUL spiculated mass with hilar lymphadenopathy as well as
mass effect on vessels/airways; EBUS on ___ had demonstrated
NSCLC at CHA. CT chest with contrast at that time also raised
concern for metastatic disease to LNs, bone, and adrenals. On
___, he presented to ___ with ongoing chest pain and DOE,
which had progressed. He also endorsed new headache, and was
subsequently found to have intracranial metastatic disease.
During that hospitalization, MRI head and spine were deferred
given known shrapnel in RUE (per notes, cleared by radiology for
MRI but pt reluctant). CT chest was negative for PE, and
demonstrated known RUL mass/R mediastinal lesion with
postobstructive consolidation (atelectasis more likely than
pneumonia given absence of cough or fever). Pt had previously
been scheduled for bronchoscopy with CHA pulmonologist Dr.
___ persistent plugging of RML/RLL; plan at that time
was to pursue bronchoscopy as outpatient. Plan was also made to
follow up with ___ oncology at pt and pt's mother's request;
thoracic oncology team planned to obtain pathology from CHA for
further testing. Intracranial metastases prompted neurosurgical
consultation; recommended outpatient f/u for further treatment
planning.
Since discharge, pt states that he thinks he has been mixing up
his medications. At present, he organizes his own medications,
but states that his mother is planning to start helping with his
medications.
Pt describes ___ substernal chest pain, worse with inspiration,
which has interfered with his ability to fall asleep
intermittently over the past ___ nights. He states that the pain
moves from his back to his front (not front to back, and not two
separate pains). Quality of pain is "like something pushing
through me," fluctuates in intensity, but persists throughout
the night. Pain has been present for about 1 month. He takes
Tylenol pm and oxycontin, tizanidine for pain, with good effect.
Pain is worse with movement.
He initially denies cough, although subsequently recalls a
productive cough, nonbloody, the details of which he cannot
recall, but believes that it occurred while using the incentive
spirometer. Denies F/C, endorses some posttussive emesis,
nonbloody. Denies abdominal pain, diarrhea, constipation,
dysuria, but he has noted darker urine. He describes weight
loss: 185 lbs 3 weeks prior, now ___ lbs. Weight loss is
unintentional.
He endorses R frontal headaches, wrapping around to L temporal
area and occiput, similar compared to prior. Denies ___ edema.
He endorses constipation for approx. 1 week, denies
bowel/bladder incontinence or urinary retention, denies saddle
anesthesia.
In the ___ ED:
VS 96.6, 121->85->100, 120/74, 100% RA
Exam notable for:
Resp: Reduced lung sounds on right side compared to left, no
wheezes or rhonchi, normal work of breathing
Cardiovascular: Regular rate and rhythm, normal ___ and ___
heart sounds
Labs notable for:
WBC 18.7, Hb 9.4, Plt 621
BUN 14, Cr 0.8
TnT<0.01 x2
BNP 106
ALT 22, AST 40
Alk phos 264
Tbili 0.3, Albumin 3.3
Serum tox negative
Imaging:
CTA chest:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Essentially unchanged evaluation from ___ ___
with a right
upper lobe pulmonary mass in addition to mediastinal and right
hilar
lymphadenopathy with resultant attenuation of the right middle
lobe bronchi
and subsequent findings suggestive of postobstructive pneumonia.
3. Innumerable lytic metastases of the ribs and thoracic spine,
notable for a
T5 destructive vertebral mass with intra canal extension, also
unchanged from
prior study.
4. 2.2 cm indeterminate right adrenal nodule may represent
metastatic disease
and is also unchanged.
Received:
Tylenol
Morphine sulfate 4 mg IV
Piperacillin-tazobactam 4.5 g IV x1
On arrival to the floor, pt provides above history.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
per prior notes, confirmed with pt:
Schizophrenia
Anxiety
Asthma
GERD
HLD
Chronic LBP and LLE pain
Stage IV lung cancer as per HPI
Social History:
___
Family History:
Aunt with history of lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: ___ 2352 Temp: 97.6 PO BP: 115/77 L Sitting HR: 100 RR:
18 O2 sat: 94% O2 delivery: Ra
GEN: alert and interactive, comfortable, no acute distress,
sitting at edge of bed
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, S1/S2 are not diminished; pulsus <4
LUNGS: Decreased breath sounds at R base, otherwise CTAB without
wheeze or rhonchi
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: A&Ox3, cranial nerves II-XII intact, strength in
bilateral
LEs is ___ including hip flexors, knee extension and flexion;
sensation to light touch intact in bilateral LEs. Gait slow,
cautious, with slightly wide gait. Pt declines UE strength
testing on admission ___ fatigue.
PSYCH: blunted affect, appropriate
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC: 18.7* RBC: 3.76* Hgb: 9.4* Hct:
29.4*
MCV: 78* MCH: 25.0* MCHC: 32.0 RDW: 15.8* RDWSD: 43.___*
___ 02:30PM BLOOD Neuts: 61.8 Lymphs: ___ Monos: 13.0 Eos:
0.1* Baso: 0.3 Im ___: 0.6 AbsNeut: 11.55* AbsLymp: 4.53*
AbsMono: 2.44* AbsEos: 0.02* AbsBaso: 0.06
___ 02:30PM BLOOD Glucose: 99 UreaN: 14 Creat: 0.8 Na: 142
K: 4.2 Cl: 95* HCO3: 27 AnGap: 20*
___ 05:36PM BLOOD ALT: 22 AST: 40 AlkPhos: 264* TotBili:
0.3
___ 05:36PM BLOOD proBNP: 106
___ 05:36PM BLOOD cTropnT: <0.01
___ 02:30PM BLOOD cTropnT: <0.01
___ 05:36PM BLOOD Albumin: 3.3*
___ 05:36PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
DISCHARGE LABS
=============
___ 06:55AM BLOOD WBC-17.4* RBC-3.33* Hgb-8.7* Hct-26.8*
MCV-81* MCH-26.1 MCHC-32.5 RDW-21.3* RDWSD-59.7* Plt ___
IMAGING
=======
EKG: Sinus tachycardia at 108 bpm, normal axis, normal intervals
(QTc 487), TW flattening in all limb leads, and in V5-V6, TWIs
in
V5, no ST segment changes, no pathologic Q waves. Compared to
prior, tachycardia and TWI flattening is new.
# CT A/P with contrast (___):
1. Re-demonstration of a 2.6 cm right adrenal nodule, which
could reflect metastasis. Mild thickening of the left adrenal
gland is indeterminate.
2. Extensive predominantly lytic osseous metastases throughout
the imaged lumbar spine and pelvis. No pathologic fractures are
seen. The L5 lesion does have a soft tissue component that
encroaches slightly on the canal. If clinically appropriate
based on neurologic examination, a lumbar spine MRI could be
performed to evaluate for tumor invasion into the spinal canal.
3. Re-demonstration of right basilar atelectasis.
# CT Head w/ contrast (___)
1. Re-identified a 1.4 cm mass anterior to the right temporal
lobe with associated osseous destruction and possible periosteal
reaction of the greater wing of the right sphenoid bone, with
possible underlying lytic changes in the left frontal bone,
concerning for possible metastasis, and extra-axial mass lesion
such as a meningioma can't be completely rule out, correlation
with MRI is
recommended.2. Unchanged 3 mm crescentic, enhancing rim along
the right frontal convexity which may represent dural
thickening, metastatic disease or subdural hemorrhage.3.
Relatively unchanged sinus disease.
# Chest CTA (___):
1. No evidence of pulmonary embolism or aortic abnormality. 2.
Essentially unchanged evaluation from CTA ___ with
a right upper lobe pulmonary mass in addition to mediastinal and
right hilar lymphadenopathy with resultant attenuation of the
right middle lobe bronchi and subsequent findings suggestive of
postobstructive pneumonia throughout the right lung.
3. Innumerable lytic metastases of the ribs and thoracic spine,
notable for a T5 destructive vertebral mass with intra canal
extension, also unchanged from prior study. 4. 2.2 cm
indeterminate right adrenal nodule may represent metastatic
disease and is also unchanged.
#CXR ___
The right pleural effusion has significantly increased in volume
since the
prior study. The mediastinal adenopathy and right hilar
adenopathy is
unchanged. The right upper lobe mass is also unchanged.
Cardiomediastinal
silhouette is stable. Radiopaque densities projecting over the
Left chest are
unchanged.
#CT HEAD ___. Re-demonstrated are multiple extra-axial soft tissue masses
with associated
bony destruction in the right temporal and bilateral frontal
lobes, which
remain concerning for possible metastasis. As before,
extra-axial mass
lesions such as a meningioma cannot be excluded.
2. Interval decrease in density in a 3 mm extra-axial collection
along the
right frontal convexity likely represents subdural hemorrhage.
3. No evidence of new hemorrhage or infarction.
#CT L SPINE ___
Destructive bone lesions along the lumbar spine, although
without evidence for
substantial lumbar spinal stenosis based on this.
#CT CHEST ___. Moderate narrowing of the superior vena cava as it enters
the atrium.
2. Marked increase in atelectasis of the right middle and lower
lobes with
the concern for superimposed infection. Correlation with
clinical
circumstances is recommended.
3. No definite short-term change in metastatic lung cancer
including
destructive spinal lesions with some encroachment into the
spinal canal at T5.
___ US ___. No evidence of deep vein thrombosis in the right upper
extremity.
2. Superficial thrombophlebitis of a branch of the right
cephalic vein near
the antecubital fossa.
#CTA NECK ___. Patent appearance of the carotid and vertebral arteries in
the neck
without evidence of stenosis, occlusion or dissection.
2. No evidence of filling defects noted within the internal
jugular and
subclavian veins.
3. There is a 2 cm irregular nodule noted along the pleura of
the right upper
lobe in the setting of bilateral pleural effusions in the
setting of known
lung cancer.
4. There is asymmetric soft tissue edema and fat stranding
noted about the
right face including the preseptal right orbital region with
diffuse
lymphadenopathy throughout the neck and mediastinum. No
evidence of
abscesses.
5. Re-identified enhancing metastatic lesion with surrounding
bony erosion of
the sphenoid involving the frontotemporal region. There is also
suspicion for
calvarial lytic lesions, permeative changes of the right frontal
calvarium and
known diffuse osseous metastases including lytic lesions within
the thoracic
spine.
#CXR ___
Heart size and mediastinum are stable. Right pleural effusion
is more
moderate associated also with atelectasis and elevation of right
hemidiaphragm. Right upper lobe pulmonary nodules better
appreciated on the
chest CT from ___. Left lung is overall clear.
There is no
interval development of left pleural effusion. There is no
appreciable
pneumothorax. No pulmonary edema.
#CTA CHEST ___. Limited evaluation of the subsegmental pulmonary arteries,
however no
evidence of central pulmonary embolism through the segmental
pulmonary
arteries. No acute aortic abnormality. No evidence of
pulmonary embolism or
aortic abnormality.
2. Minimal change in extensive right lower lobe and, to a lesser
extent, right
middle lobe atelectasis. Relative hypoattenuating opacities in
the right
middle lobe could represent pneumonia, or alternatively
infiltrative extension
of right hilar lymphadenopathy, and clinical correlation is
recommended.
3. No short-term interval change in metastatic lung cancer,
again with a
destructive bony lesion at the T5 vertebral body with
encroachment into the
vertebral canal.
4. Small right pleural effusion.
#CT HEAD WO CONTRAST ___. Moderately motion limited exam. Given the limitation,
multiple extra-axial
soft tissue masses with associated bone destruction in the right
temporal and
bilateral frontal lobes are grossly unchanged.
2. Known right frontal convexity 3 mm extra-axial collection is
also
unchanged. No new intracranial hemorrhage.
#CXR ___
The right hemidiaphragm is elevated with atelectasis in the
right lung base.
A small right pleural effusion is unchanged. No focal
consolidation or
pneumothorax is identified. The cardiomediastinal silhouette is
stable in
appearance. The opacities in the right middle lobe and right
hilar
lymphadenopathy are better appreciated on prior CT. No acute
osseous
abnormalities are identified. Metallic densities projecting
over the left
hemithorax are noted.
#EEG ___ HOUR IMPRESSION: This was an abnormal continuous video-EEG
monitoring
study due to diffuse background indicative of a mild
encephalopathy, which is nonspecific as to etiology. Common
causes include medication effects, toxic- metabolic
disturbances and/or infection. Intermittent frontally
predominant rhythmic delta slowing (FIRDA) is a nonspecific
finding and can be seen with toxic-metabolic disturbances and
deep midline lesions. There are no electrographic seizures.
MICRO
======
# ___ LP (___): TNC 6, RBC 1, TP 140, Gluc 37, LDH 40
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing
2. Amitriptyline 50 mg PO QHS
3. Benztropine Mesylate 0.5 mg PO BID
4. BuPROPion 100 mg PO BID
5. Divalproex (DELayed Release) 500 mg PO BID
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Gabapentin 800 mg PO TID
8. Prazosin 1 mg PO QHS:PRN nightmares
9. RisperiDONE 4 mg PO QHS
10. RisperiDONE 1 mg PO DAILY:PRN Agitation
11. Simvastatin 40 mg PO QPM
12. Venlafaxine XR 225 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HydrOXYzine 25 mg PO Q8H:PRN Itching
15. Tizanidine 2 mg PO TID
16. varenicline 1 mg oral BID
17. MetFORMIN (Glucophage) 500 mg PO DAILY
18. Percocet (oxyCODONE-acetaminophen) 10 mg oral Q4H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary dx
Metastatic lung cancer
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 chest pain and hx cancer// ? effusion/ PNA
COMPARISON: Prior CT of the chest from ___
FINDINGS:
PA and lateral views of the chest provided. Multiple metallic BBs are seen
projecting over the chest likely representing retained foreign bodies. There
is persistent right basal opacity which likely represents a combination of
residual consolidation and trace effusion. The overall appearance is not
significantly changed from prior CT allowing for differences in technique.
Known right hilar and right upper lobe masses are not well visualized.
Cardiomediastinal silhouette appears stable. Bony structures appear grossly
unchanged.
IMPRESSION:
Persistent right basal opacity remains concerning for residual consolidation
and possible tiny associated effusion. Known right hilar and right upper lobe
mass is better assessed on prior CT.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with pleuritic chest pain and shortness of breath.//
Pulmonary embolism?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 473 mGy-cm.
COMPARISON: CTA chest from ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is a re-demonstrated right hilar
lymphadenopathy with a conglomerate encasing and attenuating the right
pulmonary artery measuring approximately 4.6 x 2.5 cm, unchanged from prior
study. Additional enlarged mediastinal lymph nodes are demonstrated in the
subcarinal region and are also unchanged no axillary or left hilar
lymphadenopathy is present.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Again seen in the anterior right upper lobe is a 3.0 x 2.1 cm
pulmonary mass, unchanged from prior. The above described right hilar nodal
mass encases the right middle lobe bronchi with resultant hypodense
consolidation in the right upper, middle, and lower lobes concerning for
postobstructive pneumonia, and is also unchanged. Atelectasis is demonstrated
at the right lung base. Moderate centrilobular emphysema is demonstrated
throughout bilaterally, otherwise the left lung is clear. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: An enlarged right thyroid lobe without discrete nodularity is
again demonstrated.
ABDOMEN: Included portion of the upper abdomen is notable for a 2.2 cm right
adrenal nodule, also unchanged.
BONES: There is re-demonstration of multiple osseous lytic lesions throughout
the ribs and vertebral bodies highly concerning for metastatic disease, all of
which are grossly unchanged, and most notable for the T5 vertebral body
destructive lytic mass with soft tissue extension into the anterior spinal
canal, similar in appearance to prior.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Essentially unchanged evaluation from CTA ___ with a right
upper lobe pulmonary mass in addition to mediastinal and right hilar
lymphadenopathy with resultant attenuation of the right middle lobe bronchi
and subsequent findings suggestive of postobstructive pneumonia throughout the
right lung.
3. Innumerable lytic metastases of the ribs and thoracic spine, notable for a
T5 destructive vertebral mass with intra canal extension, also unchanged from
prior study.
4. 2.2 cm indeterminate right adrenal nodule may represent metastatic disease
and is also unchanged.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ with hx of paranoid schizophrenia, NIDDM, recently diagnosed
stage IV lung cancer not yet undergoing treatment presenting with acute on
chronic chest pain in thesetting of widely metastatic disease. Has mets to
brain, complains of headache. Prior attempt of LP as inpt was unsuccessful.
Had outpt ___ LP scheduled for ___, but now needing expedited care.//
obtain LP for cytology
TECHNIQUE: After informed consent was obtained from the patient and mother
explaining the risks, benefits, and alternatives to the procedure, the
patient was laid in prone position on the fluoroscopic table. A pre-procedure
time-out was performed confirming the patient's identity, relevant history,
procedure to be performed and labs.
Puncture was performed at L4-5.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted
into the thecal sac. There was good return of clear CSF. 16 mls of CSF were
collected in 4 tubes and sent for requested analysis. Additional 4 mL CSF was
collected in a single cytology tube.
COMPARISON: None.
FINDINGS:
Successful lumbar puncture was performed at L4-5.
16 mls of CSF were collected in 4 tubes and 4 mL of CSF was collected in a
single cytology tube.
IMPRESSION:
1. Lumbar puncture at L4-L5 without complication.
I, Dr. ___ supervised the trainee during the key components
of the above procedure and I reviewed and agree with the trainee's findings
and dictation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with widely metastatic lung cancer// New hypoxia
after chest radiation
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The right pleural effusion has significantly increased in volume since the
prior study. The mediastinal adenopathy and right hilar adenopathy is
unchanged. The right upper lobe mass is also unchanged. Cardiomediastinal
silhouette is stable. Radiopaque densities projecting over the Left chest are
unchanged.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with known metastatic lung cancer, mets to
brain// Acute onset lethargy this AM
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
752.0 mGy-cm.
2) Stationary Acquisition 2.0 s, 7.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
376.0 mGy-cm.
Total DLP (Head) = 1,128 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
Re-demonstrated is a thin, 3 mm subdural collection along the right frontal
convexity. While the more posterior aspect remains hyperdense, most of the
collection appears more hypodense. The 1.4 x 1.3 cm extra-axial soft tissue
density anterior to the right temporal lobe (5:9) is unchanged, and may
represent a metastatic lesion or meningioma. There is unchanged periosteal
reaction with surrounding osseous destruction of the greater wing of the
sphenoid bone. A 0.7 x 0.6 cm possible lytic lesion in the left frontal bone
(05:12) is unchanged. There is unchanged soft tissue thickening overlying the
right frontal bone.
There is no evidence of fracture, infarction,hemorrhage, or edema. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Mild periventricular and subcortical white matter hypodensities are
nonspecific, but likely represent sequela of chronic ischemic microvascular
disease.
There is increasing opacification of the right frontal sinus, and mild mucosal
thickening in the left frontal sinus, bilateral ethmoid air cells and
bilateral maxillary sinuses. Otherwise, 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:
1. Re-demonstrated are multiple extra-axial soft tissue masses with associated
bony destruction in the right temporal and bilateral frontal lobes, which
remain concerning for possible metastasis. As before, extra-axial mass
lesions such as a meningioma cannot be excluded.
2. Interval decrease in density in a 3 mm extra-axial collection along the
right frontal convexity likely represents subdural hemorrhage.
3. No evidence of new hemorrhage or infarction.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST Q412
INDICATION: ___ year old man with known metastatic lung cancer, now with
increased facial swelling. // CT VenogramPost contrast CT venogram to
evaluate for SVC syndrome
TECHNIQUE: Multidetector CT images of the chest were obtained without
intravenous contrast. This was followed by delayed contrast-enhanced imaging
of the chest. Sagittal and coronal reformations of the contrast-enhanced
series are included in the study.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 3.8 mGy (Body) DLP = 112.4
mGy-cm.
2) Spiral Acquisition 4.6 s, 29.7 cm; CTDIvol = 11.0 mGy (Body) DLP = 319.1
mGy-cm.
Total DLP (Body) = 432 mGy-cm.
COMPARISON: ___.
FINDINGS:
The superior vena cava is patent. The cavoatrial junction is somewhat
narrowed. Minimum caliber is about 8 mm in diameter compared to background
diameter of 20 mm.
The heart is borderline in size.
There is a small right-sided pleural effusion and a trace left-sided pleural
effusion, both new. Invasive right hilar and subcarinal lymphadenopathy
appears unchanged. A number of other mildly prominent mediastinal lymph nodes
also show no definite short-term change.
A large medial right upper lobe nodule is unchanged. Emphysema is mild.
The right lower lobe shows much more extensive opacification with air
bronchograms, and the right middle lobe is now collapsed with a relatively
hypoattenuating appearance raising concern for pneumonia.
Limited views of the upper abdomen show right adrenal masses suggesting
metastatic disease and more equivocal thickening of the left adrenal but
probably also involved with metastatic disease. Dysmorphic spleen, as before.
Widespread predominantly blastic skeletal metastases demonstrate no short
definite short-term change. Moderately extensive lytic lesions are most
striking in T1, T3 and T5, as before. T5 is again partly collapsed with a
soft tissue mass mildly encroaching into the spinal canal as before.
IMPRESSION:
1. Moderate narrowing of the superior vena cava as it enters the atrium.
2. Marked increase in atelectasis of the right middle and lower lobes with
the concern for superimposed infection. Correlation with clinical
circumstances is recommended.
3. No definite short-term change in metastatic lung cancer including
destructive spinal lesions with some encroachment into the spinal canal at T5.
Radiology Report
EXAMINATION: CT L-SPINE W/ CONTRAST Q332
INDICATION: ___ year old man with metastatic lung cancer and ___ weakness //
Eval for large lumbar mets
TECHNIQUE: Multidetector CT images of the lumbar spine were obtained after
delayed contrast administration. Sagittal and coronal reformations were also
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.7 s, 36.1 cm; CTDIvol = 22.4 mGy (Body) DLP = 794.6
mGy-cm.
Total DLP (Body) = 795 mGy-cm.
COMPARISON: CT of the abdomen and pelvis is available from ___.
FINDINGS:
There is extensive mixed lytic and blastic disease. This demonstrates no
short-term change. Moderately large lytic lesion is noted along the anterior
L2 vertebral body in addition other lesions. An L5 lesion involves the left
posterior part of the spinal canal including soft tissue mass partly growing
posteriorly into the spinal canal, yielding mild spinal stenosis only, and
narrowing of the left L5-S1 neural foramen. There is an extensive metastasis
involving the right ilium and destructive lesion and at unchanged along the
anterior column of the right acetabulum, partly imaged. Additional lesions
include medium-sized lytic lesion in the left ilium.
Two suspicious right adrenal masses suggest metastatic disease without
short-term change. The left adrenal is thickened, possibly involved with
metastatic disease. Trace free fluid is found in the pelvic cul de sac.
Atherosclerotic calcification is moderate.
IMPRESSION:
Destructive bone lesions along the lumbar spine, although without evidence for
substantial lumbar spinal stenosis based on this.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: ___ year old man with metastatic lung cancer // Venous phase
pleaseUnilateral swelling of right face
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
3) Stationary Acquisition 7.1 s, 0.2 cm; CTDIvol = 113.4 mGy (Head) DLP =
22.7 mGy-cm.
4) Spiral Acquisition 4.1 s, 26.7 cm; CTDIvol = 32.7 mGy (Head) DLP = 851.3
mGy-cm.
5) Spiral Acquisition 4.1 s, 26.7 cm; CTDIvol = 32.7 mGy (Head) DLP = 851.3
mGy-cm.
Total DLP (Head) = 1,731 mGy-cm.
COMPARISON: None.
FINDINGS:
CTA neck:
The left vertebral artery originates directly from the aortic arch. This is
an anatomic variant. There is minimal calcification of the aortic arch and
carotid bifurcations bilaterally. Right dominant vertebral artery. No stenosis
of the internal carotid arteries bilaterally by NASCET criteria.
CT angiography of the neck shows patent appearance of the carotid and
vertebral arteries without stenosis or occlusion or dissection.
CTV neck: No evidence of filling defects within the internal jugular and
partially imaged subclavian veins.
Other: There is a 2 cm irregular nodule appreciated along the pleura of the
right upper lobe (4:1). Bilateral pleural effusions, right greater than left.
Emphysematous changes noted in the right apex. Multiple metallic fragments
are noted within the soft tissues of the left hemithorax, possibly bullet
fragments. The thyroid gland appears grossly unremarkable.
Asymmetric soft tissue edema and fat stranding noted throughout the right
face, including the preseptal right orbital region. No evidence of abnormal
fluid collections. There are enlarged lymph nodes in the supraclavicular
region bilaterally measuring 1.4 cm on the right (06:59) and 1 cm on the left
(6:70). Another 1 cm lymph node noted in level 2B on the left (6:146).
Prominent lymph nodes also noted within the mediastinum measuring upwards of 1
cm (6:19).
Re-identified enhancing metastatic lesion with bony erosion of the sphenoid
(4:191). Calvarial lesions of with adjacent soft tissue are also suspicious
for lytic lesions (04: 192, 204). The right frontal calvarium involves
permeative changes (04:201). Partially visualized subdural hemorrhage is
re-identified along the right convexity (04:202). Mild mucosal thickening seen
in the bilateral maxillary sinuses and ethmoid air cells (4:153). Near
complete opacification of the right frontal sinus (4:182).
Patient with known diffuse skeletal metastases including a 1 cm lytic lesion
within the T1 vertebral body (6:79). Mild multilevel degenerate changes of
visualized spine with prominent anterior osteophyte at C5. No high-grade
spinal canal stenosis.
IMPRESSION:
1. Patent appearance of the carotid and vertebral arteries in the neck
without evidence of stenosis, occlusion or dissection.
2. No evidence of filling defects noted within the internal jugular and
subclavian veins.
3. There is a 2 cm irregular nodule noted along the pleura of the right upper
lobe in the setting of bilateral pleural effusions in the setting of known
lung cancer.
4. There is asymmetric soft tissue edema and fat stranding noted about the
right face including the preseptal right orbital region with diffuse
lymphadenopathy throughout the neck and mediastinum. No evidence of
abscesses.
5. Re-identified enhancing metastatic lesion with surrounding bony erosion of
the sphenoid involving the frontotemporal region. There is also suspicion for
calvarial lytic lesions, permeative changes of the right frontal calvarium and
known diffuse osseous metastases including lytic lesions within the thoracic
spine.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with metastatic lung cancer and RUE swelling //
RUE doppler to eval for DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
Right upper extremity duplex ultrasound
COMPARISON: No priors are available for comparison
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The basilic vein is
patent, compressible and show normal color flow. There is thrombus in a
branch of the right cephalic vein near the antecubital fossa, consistent with
superficial thrombophlebitis.
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper extremity.
2. Superficial thrombophlebitis of a branch of the right cephalic vein near
the antecubital fossa.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with metastatic lung cancer and post obstructive
pneumonia, now with tachycardia and hypoxia // Evaluate for pulmonary edema,
pneumonia. Evaluate for pulmonary edema, pneumonia.
IMPRESSION:
Heart size and mediastinum are stable. Right pleural effusion is more
moderate associated also with atelectasis and elevation of right
hemidiaphragm. Right upper lobe pulmonary nodules better appreciated on the
chest CT from ___. Left lung is overall clear. There is no
interval development of left pleural effusion. There is no appreciable
pneumothorax. No pulmonary edema.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with metastatic lung cancer, tachycardia, mild
new hypoxia // assess for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
4) Stationary Acquisition 4.6 s, 0.2 cm; CTDIvol = 77.0 mGy (Body) DLP =
15.4 mGy-cm.
5) Spiral Acquisition 5.4 s, 35.1 cm; CTDIvol = 10.0 mGy (Body) DLP = 344.5
mGy-cm.
Total DLP (Body) = 365 mGy-cm.
COMPARISON: CT chest from ___ and ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus.
Limited evaluation of the subsegmental pulmonary arteries due to motion
artifact. The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. The main pulmonary artery is top normal in
caliber. The heart, pericardium, and great vessels are unchanged. The
superior vena cava remains patent. Narrowing of the superior vena cava near
the cavoatrial junction to 9 mm is similar to prior study from ___. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Extensive, infiltrative right hilar and
mediastinal lymphadenopathy is grossly unchanged compared to the prior study
from ___.
PLEURAL SPACES: Trace right pleural effusion is unchanged. No pneumothorax.
LUNGS/AIRWAYS: A paramediastinal right upper lobe mass measuring 3.1 cm is
unchanged (series 6:110). There is extensive atelectasis and volume loss in
the right lower lobe, and to a lesser extent the right middle lobe, similar to
the immediate prior study. Relative hypoattenuating opacities in the right
middle lobe could represent pneumonia/infection, or extension of extensive
right hilar lymphadenopathy.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is notable for a 2.8 cm right
adrenal mass, concerning for metastatic disease. Thickening of the left
adrenal gland is similar to the previous study, also suspicious for metastatic
involvement. Dysmorphic splenic appearance is unchanged.
BONES: Redemonstration of widespread skeletal metastases including lytic
lesions in the T1, T3, T5, and T12 vertebral bodies. Compression deformity of
T5 is unchanged, with soft tissue density material extending into the
vertebral canal, unchanged.
IMPRESSION:
1. Limited evaluation of the subsegmental pulmonary arteries, however no
evidence of central pulmonary embolism through the segmental pulmonary
arteries. No acute aortic abnormality. No evidence of pulmonary embolism or
aortic abnormality.
2. Minimal change in extensive right lower lobe and, to a lesser extent, right
middle lobe atelectasis. Relative hypoattenuating opacities in the right
middle lobe could represent pneumonia, or alternatively infiltrative extension
of right hilar lymphadenopathy, and clinical correlation is recommended.
3. No short-term interval change in metastatic lung cancer, again with a
destructive bony lesion at the T5 vertebral body with encroachment into the
vertebral canal.
4. Small right pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with metastatic lung cancer with brain mets and
worsening confusion. // Evaluate for brain mets, bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
2) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 1,711 mGy-cm.
COMPARISON: CT head dated ___ and ___.
FINDINGS:
Study is moderately limited by motion. Given the limitation, the known right
frontal convexity iso to hypodense subdural collection with hyperdense
component posteriorly is likely not significantly changed. The known
extra-axial soft tissue density anterior to the right temporal lobe is
suboptimally visualized on today's exam but grossly similar. Osseous
destruction of the greater wing of the sphenoid bone adjacent to this lesion
is again noted. Bilateral frontal bone lytic lesion along the inner table are
unchanged. Right frontal scalp soft tissue thickening is unchanged. No new
intracranial hemorrhage. There is no evidence of large territory infarction,
edema,or mass. The ventricles and sulci are normal in size and configuration.
No fracture. Opacification of the right frontal, ethmoid air cells, and right
sphenoid sinus are unchanged. Mucosal thickening of the bilateral maxillary
sinuses is also unchanged. The mastoid air cells and middle ear cavities are
clear. The visualized portion of the orbits are normal.
IMPRESSION:
1. Moderately motion limited exam. Given the limitation, multiple extra-axial
soft tissue masses with associated bone destruction in the right temporal and
bilateral frontal lobes are grossly unchanged.
2. Known right frontal convexity 3 mm extra-axial collection is also
unchanged. No new intracranial hemorrhage.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with tachypnea, tachycardia, AMS // evaluate
effusion, infection
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___. CTA chest ___.
IMPRESSION:
The right hemidiaphragm is elevated with atelectasis in the right lung base.
A small right pleural effusion is unchanged. No focal consolidation or
pneumothorax is identified. The cardiomediastinal silhouette is stable in
appearance. The opacities in the right middle lobe and right hilar
lymphadenopathy are better appreciated on prior CT. No acute osseous
abnormalities are identified. Metallic densities projecting over the left
hemithorax are noted.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 96.6
heartrate: 121.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | PATIENT SUMMARY
=============
Mr. ___ is a ___ year old man with history of newly
diagnosed stage IV NSCLC and paranoid schizophrenia who was
initially admitted to the HMED and then OMED services for
expedited work up of his metastatic cancer, then transferred to
the FICU for AMS likely ___ Leptomeningeal carcinomatosis which
responded to high dose dexamethasone then back to OMED for
continued management, radiation, and steroids ,with plan for
radiation through ___ and discharge to rehab.
# Metastatic NSCLC
# Right ptosis and right sided facial swelling
Mets to brain (R frontal), ribs, thoracic spine, lumbar spine, R
adrenals. Pt s/p fluoroscopic guided LP, CSF cytology negative
though protein is elevated to 140 c/f leptomeningeal spread. S/p
XRT to chest area ___ with improvement in chest pain (sternal
bone XRT only--did not treat intrathoracic tumor). Plan remains
to complete palliative RT here in the hospital until ___ and
then to pursue all further cancer care as an outpatient after
d/c
from rehab with Dr. ___. Awaiting final genetic studies,
tumor molecular profiling and f/u path from CHA slides (received
___ to determine potential
chemo/immunotherapy options - as outpatient. Palliative care
involved.
# AMS - Resolved
Acute onset lethargy on ___ possibly due to infection, which
resolved spontaneously, worsened again on ___ on the floor and
triggered x 2 for somnolence. Mental status has waxed and waned
in ICU. EEG with diffuse slowing, no seizure. Suspect related to
leptomeningeal involvement of NSCLC which improved with
steroids.
Infectious studies negative - Bcx, ucx. MRI not obtained d/t
chest shrapnel. Held sedating agents. Pt on dexamethasone while
inpatient 4mg IV q12 hours, He will continue dexamethasone 4mg
PO BID until follow-up with Dr. ___ neurooncologist on
___. While he is on dexamethasone he should continue
Bactrim DS and PPI. Received Keppra load ___ and then on
maintenance 500mg.
# Post-obstructive pneumonia - Resolved
# Leukocytosis
# Moderate right pleural effusion
# Tachypnea
Pt lethargic ___ and ___ with WBC uptrending, afebrile but
with lethargy.
CT chest showed possible post-obstructive PNA. Initially on
broad
spectrum abx, then narrowed to CTX and azithro when MRSA
negative. However, given c/f worsening AMS, broadened to Zosyn;
WBC downtrended, abx completed on ___. BCx NGTD.
# Anemia:
Past studies with low iron, low TIBC and elevated ferritin
suggestive of anemia of chronic disease, as well as low
transferrin sat, elevated RDW-SD c/f iron deficiency anemia as
well. Hb trending down iso continuous IVF. Pt currently not
complaining of chest pain or dizziness. s/p 1uPRBCs on ___,
stable.
# Hypercalcemia
PTH-rp negative during last admission, Corrected Ca ___.
Low PTH on ___, PTH-rp low on ___. s/p pamidronate ___,
will need repeat and followup (see transitional issues).
# Transient ___ weakness (resolved)
# Lytic bone lesions with T5 vertebral body with concern for
soft
tissue extension into the spinal canal He had transient
bilateral
___ weakness on ___. CT lumbar spine
showed destructive bone lesions along the lumbar spine, though
without obvious spinal stenosis (would be better evaluated by
MRI). Unable to obtain MRI during prior hospitalization given
known shrapnel. ___ strength returned to normal, no
urinary/fecal incontinence/retention, no ___, no
saddle anesthesia.
# Acute on chronic chest pain
# Acute on chronic dyspnea
Pain localized to R-side coinciding with the location of R ant
lung mass invading into the rib. CT with R lesion and R pleural
effusion. CTA chest negative for PE. No signs of tamponade. Has
had persistent leukocytosis without fevers, and endorses some
cough, but no PNA on CXR. S/p XRT to chest ___ with improvement
in sx. On exam with consistently decreased breath sounds on
right lung.
#___
Palliative care has been following for assistance with pain
management and GOC discussions. Mom, HCP was starting to
think about hospice care. However, is interested in
pursuing more diagnostic evaluation. Pt with 9 biological
children
from young age up to in their ___, and is close with some but
not
all of them. Some have been visiting hospital but it is unclear
how much family knows of his critical illness. Further
chemotherapy and treatment options to be discussed with
outpatient oncologist.
CHRONIC ISSUES
=============================
# Schizophrenia:
He has a history of schizophrenia with paranoia that is well
controlled. Is an active member of his community.
- home buproprion SR 150mg PO BID, Risperidone 4mg PO QHS,
Prazosin 1mg PO QHS PRN, depakote 500mg PO BID, benztropine
0.5mg
PO BID Initially risperidone and tizanidine held d/t
sedation/AMS but restarted home Risperidone 1mg PO daily PRN
___, restarted tizanidine ___
# Diabetes: Held home metformin and ISS given pt not
hyperglycemic.
# Asthma: Home albuterol, fluticasone.
CORE MEASURES
# CODE: Full
# CONTACT: Mom, ___: ___
TRANSITIONAL ISSUES
===================
[] PAML is inaccurate; per pt's mother meds are what is in our
computer however med rec with pharmacy is different. Needs
further reconciliation and titration with PCP. Stabilized on
current regimen while in hospital thus discharged on this
regimen.
[] Initiation of zoledronic acid IV every 12 weeks for
prevention of skeletal-related events is recommended on an
outpatient basis. ___ has received a dose of IV pamidronate
___.
[] Dexamethasone taper: Continue 4mg BID until follow up with
Dr. ___ on ___ Must be on DS Bactrim and
PPI while on Dexamethasone |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abacavir / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Cardioversion In ED
History of Present Illness:
HPI attained by MERIT in ED and corroborated with patient on
arrival to floor.
___ with HIV on HAART (CD4 281 on ___, on dolutegravir,
darunavir, and lamuvidine), a fib on metoprolol, amiodarone
apixaban, rheumatic heart disease s/p bioprosthetic AV/MV
(biopresthetic valve AVR ___, ___ ___, CAD s/p CABG x 2 with
multiple PCRs, CKD, HFpEF >55% ___, and bladder cancer c/b
urethral stricture who presents with palpitations, found to be
in
afib.
Palpitations have been present for ___ days. He had been
instructed to take extra doses of metoprolol if he experienced
palpitations, so he had been doing so without much effect. He
reported no chest pain. He has had dyspnea but could be chronic
since recent hospital stay.
His afib history is as follows: S/p 5 DCCV s/p PVI ___, s/p AT
ablation ___, s/p PCM on ___ for tachy-brady, had a
presentation for afib in ___ during which he was started on
metop (previously only on amio and apixaban, previously on coreg
but this had been discontinued on a prior presentation BEFORE
___.
Had recent prolonged hospitalization for dyspnea, admitted ___
with discharge to home on ___. During that admission, dyspnea
had thorough workup including EBUS and BAL without evidence of
malignancy or infection; diagnosis of exclusion was ILD. The
etiology of his breathing problem is unclear but it did occur
after his building was being reconstructed with replacement of
asbestos pipes. Of note he also became anemic and was found to
have esophagitis on EGD. He was treated for UTI with E.coli at
his prior hospital stay, received 5 days (end ___ of
antibiotics (ceftriaxone, zosyn). He also has a history of
klebsiella UTI in ___ to ___. Note he is DNR/DNI but ok
for transfer to hospital.
He has been taking prednisone 40mg/day for interstitial lung
disease at his last hospital stay. He was initiated on
atovaquone
because of PCP prophylaxis while on steroids.
Regarding his HIV: He was seen by Dr. ___ on ___. Plan
to
recheck HIV viral load at next office visit in one month.
Regarding his breathing: He was seen at ___ clinic on ___ for
follow-up of pulmonary infiltrates and mediastinal
lymphadenopathy. He reported during that clinic visit that he
had
no improvement with his steroids and that he is still using his
oxygen.
Regarding his urinary retention: He was seen at ___ clinic
on
___ and passed voiding trial with no PVR. He was able to
self
cath easily. He was to discuss with PCP about moving urology
care
permanently to ___.
Past Medical History:
1. Rheumatic heart disease with AS/MS, S/P bioprosthetic AVR and
MVR in ___, and repeat bioprosthetic AVR in ___
2. Severe bioprosthetic mitral regurgitation, S/P 26 ___
___ in ___, complicated by HCAP with ESBL
3. CAD S/P CABG in ___ (SVG-PDA, SVG-OM1), uUnsuccessful PCI of
occluded OM1 branch and successful PCI of the distal LCx with a
2.5x18mm Endeavor DES in ___, and redo CABG in ___ (LIMA-LAD, SVG-PDA, SVG-D1)
4. Atrial fibrillation, S/P DCCV ___ and ___, PVI
catheter ablation ___, DCCV ___ and ablation ___,
currently on amiodarone and apixiban
5. Tachy-brady syndrome, S/P PPM ___
6. HFpEF (EF 62% ___
6. Hypertension
7. Hyperlipidemia
8. Pulmonary hypertension
9. HIV ___ CD4 count 340, VL 1.5)
10. Low grade bladder neoplasm S/P resection
___. Recurrent UTI
12. BPH
Social History:
___
Family History:
Father had a history of throat cancer. Otherwise no history of
sudden cardiac death, cardiac arrhythmias, myocardial infarction
or stroke.
Physical Exam:
VITALS: Temp: 97.7 (Tm 97.7), BP: 102/69, HR: 113, RR: 18, O2
sat: 97%, O2 delivery: 2L
GENERAL: Elderly male sitting comfortably, Alert and
interactive.
No acute distress.
HEENT: NCAT. Sclera anicteric and without injection
NECK: mildly elevated JVD
CARDIAC: irregularly irregular tachycardia. Audible S1 and S2.
No
murmurs/rubs/gallops.
LUNGS: Bilateral crackles (R>L). No wheezes, rhonchi or rales.
No
accessory muscle use
ABDOMEN: Normal bowels sounds, non distended, no guarding, no
rebound
EXTREMITIES: No edema.
SKIN: Warm. No visible rash.
NEUROLOGIC: Purposeful limb movement against gravity, fluent
speech, alert and oriented.
Discharge Exam:
VS: ___ 0743 Temp: 97.6 PO BP: 117/68 HR: 90 RR: 18 O2 sat:
96% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple
CV: irregularly irregular rhythm, no murmurs/rubs/gallops
PULM: crackles at left lung base
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no masses
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ irregular radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, able to transfer from chair to bed independently
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Lab Results
___ 10:50AM BLOOD WBC-18.0* RBC-4.77 Hgb-13.7 Hct-42.3
MCV-89 MCH-28.7 MCHC-32.4 RDW-20.7* RDWSD-67.2* Plt ___
___ 10:50AM BLOOD Neuts-93.4* Lymphs-3.2* Monos-1.9*
Eos-0.3* Baso-0.2 Im ___ AbsNeut-16.84* AbsLymp-0.58*
AbsMono-0.34 AbsEos-0.06 AbsBaso-0.03
___ 10:50AM BLOOD ___ PTT-30.0 ___
___ 10:50AM BLOOD Glucose-187* UreaN-24* Creat-1.1 Na-130*
K-4.7 Cl-93* HCO3-24 AnGap-13
___ 10:50AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:50AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0
Pertinent Interval Labs:
___ 07:16AM BLOOD WBC-18.3* RBC-4.42* Hgb-12.6* Hct-38.9*
MCV-88 MCH-28.5 MCHC-32.4 RDW-19.9* RDWSD-63.5* Plt ___
___ 07:16AM BLOOD Neuts-77.4* Lymphs-14.3* Monos-5.7
Eos-1.4 Baso-0.2 Im ___ AbsNeut-14.41* AbsLymp-2.66
AbsMono-1.07* AbsEos-0.26 AbsBaso-0.03
___ 06:50AM BLOOD ___ PTT-78.4* ___
___ 07:16AM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-136
K-4.3 Cl-96 HCO3-27 AnGap-13
___ 07:16AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.4
Sigmoidoscopy results:
Moderate diverticulosis
Dried blood present up to 30cm no fresh blood notified.
Imaging Results:
CXR: ___
IMPRESSION:
No substantial short-term change.
CXR: ___
FINDINGS:
In comparison with the prior study from ___, pulmonary
opacities are
again seen, more diffuse on the right, with slight interval
improvement since
___, slight interval improvement in aeration of the
right lung.
Again, difficult to separate the contribution made by
interstitial lung
disease, possible superimposed pneumonia/aspiration, and
possible asymmetric
pulmonary edema. No large pleural effusion is seen. No
evidence of
pneumothorax. Patient is status post median sternotomy and
aortic valve
repair. Left-sided dual lead pacemaker is stable in position.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Amiodarone 200 mg PO DAILY
3. Apixaban 2.5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Baclofen 10 mg PO TID:PRN Muscle Spasms
7. Docusate Sodium 100 mg PO BID
8. Dolutegravir 50 mg PO DAILY
9. LaMIVudine 150 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Oxazepam 10 mg PO QHS:PRN insomnia
12. Omeprazole 20 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Atovaquone Suspension 1500 mg PO DAILY PCP ___
15. Mirtazapine 15 mg PO QHS
16. PredniSONE 40 mg PO DAILY
17. Darunavir 800 mg PO BID
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Prochlorperazine 5 mg PO BID:PRN nausea
20. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 1 pill oral DAILY
21. Metoprolol Tartrate 25 mg PO PRN Palpitations with elevated
heart rates
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl 240 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
4. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Omeprazole 20 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Apixaban 2.5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Atovaquone Suspension 1500 mg PO DAILY PCP ___
11. Baclofen 10 mg PO TID:PRN Muscle Spasms
12. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 1 pill oral DAILY
13. Darunavir 800 mg PO BID
14. Docusate Sodium 100 mg PO BID
15. Dolutegravir 50 mg PO DAILY
16. LaMIVudine 150 mg PO DAILY
17. Mirtazapine 15 mg PO QHS
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Oxazepam 10 mg PO QHS:PRN insomnia
20. PredniSONE 40 mg PO DAILY
21. Prochlorperazine 5 mg PO BID:PRN nausea
22. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Atrial Fibrillation with rapid ventricular response
Lower GI bleed: undifferentiated.
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 dyspnea, palpitations// evaluate for pna, pulm
edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
In comparison with the prior study from ___, pulmonary opacities are
again seen, more diffuse on the right, with slight interval improvement since
___, slight interval improvement in aeration of the right lung.
Again, difficult to separate the contribution made by interstitial lung
disease, possible superimposed pneumonia/aspiration, and possible asymmetric
pulmonary edema. No large pleural effusion is seen. No evidence of
pneumothorax. Patient is status post median sternotomy and aortic valve
repair. Left-sided dual lead pacemaker is stable in position.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Increasing leukocytosis and worsening atrial fibrillation.
History of interstitial lung disease.
COMPARISON: ___.
FINDINGS:
Patient is status post endovascular aortic valve repair. Patient is also
status post coronary artery bypass graft surgery. Pacemaker/ICD device
appears unchanged. Cardiac, mediastinal and hilar contours appear stable
including mild cardiomegaly. There are small pleural effusions, probably
unchanged. There is no pneumothorax. Heterogeneous opacification of each
lung, right greater than left, suggests pneumonia, which is most striking in
the right upper lobe. There is probably a pattern of waxing and waning
pulmonary edema that coincides. There is little if any significant change
since the recent prior examination.
IMPRESSION:
No substantial short-term change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Palpitations
Diagnosed with Palpitations
temperature: 98.0
heartrate: 129.0
resprate: 20.0
o2sat: 99.0
sbp: 92.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY STATEMENT FOR ADMISSION
Mr. ___ is a ___ gentleman with HIV on HAART,
paroxysmal a fib on apixaban, rheumatic heart disease s/p
bioprosthetic AV/MV, CAD s/p CABG, CKD, HFpEF and bladder cancer
who presented with palpitations s/p cardioversion and CXR
initially c/f pneumonia but with reassuring exam. Now
hemodynamically stable off antibiotics and awaiting further
workup of recurrent afib. |
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:
___: ERCP/ sphincterotomy
___ laparoscopic cholecystectomy
History of Present Illness:
___ year old female who presented to the hospital with upper
abdominal pain x3 days found to have gallstone pancreatitis and
probable ___ transferred from OSH for ERCP,
which is planned for tomorrow (now this) AM.
Reports N/V x1 at time of onset of pain, none since. Pain
described as across upper abdomen, nonradiating, has not moved
since onset. Laying on R side aggravates pain, laying flat
supine
alleviates pain. Reports chills at home and temp of ___ F at
OSH.
Last ate 1.5 days ago (___). Last BM unknown, not
"today" (yesterday), which she considers constipated for her.
Denies diarrhea or blood in stool. Denies HA, dizziness, CP,
SOB,
dysuria, hematuria, sick contacts.
Past Medical History:
GERD
-avascular necrosis b/l shoulders
-arthritis
-??? asthma
Social History:
___
Family History:
Mother died of pancreatic CA at ___
-Father died of lung CA at ___ (smoker)
-Pt thinks her sister had/has gallstones
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 98.3, 77, 132/72, 16, 98% RA, 70
GEN: A&O, NAD, well appearing
HEENT: mucus membranes moist, mild scleral icterus
CV: RRR
PULM: Breathing comfortably on room air laying supine
ABD: Soft, distended, epigastric tenderness w guarding, no
rebound, very mild RUQ tenderness, no masses or hernias
appreciated
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:25AM BLOOD WBC-9.9 RBC-3.13* Hgb-10.2* Hct-30.8*
MCV-98 MCH-32.6* MCHC-33.1 RDW-16.4* RDWSD-59.1* Plt ___
___ 07:55AM BLOOD WBC-10.0 RBC-3.14* Hgb-10.2* Hct-30.0*
MCV-96 MCH-32.5* MCHC-34.0 RDW-16.0* RDWSD-55.9* Plt ___
___ 08:39PM BLOOD WBC-14.3* RBC-3.63* Hgb-11.8 Hct-35.4
MCV-98 MCH-32.5* MCHC-33.3 RDW-15.1 RDWSD-54.2* Plt ___
___ 08:39PM BLOOD Neuts-90.2* Lymphs-1.1* Monos-7.5
Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.93* AbsLymp-0.16*
AbsMono-1.07* AbsEos-0.00* AbsBaso-0.03
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-141
K-4.0 Cl-105 HCO3-25 AnGap-11
___ 07:55AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-143
K-3.8 Cl-106 HCO3-25 AnGap-12
___ 08:39PM BLOOD Glucose-54* UreaN-13 Creat-0.9 Na-138
K-4.0 Cl-102 HCO3-19* AnGap-17
___ 06:25AM BLOOD ALT-109* AST-64* AlkPhos-391* TotBili-1.5
___ 07:55AM BLOOD ALT-121* AST-64* AlkPhos-398*
TotBili-3.4*
___ 06:25AM BLOOD Lipase-294*
___ 08:39PM BLOOD Lipase-1251*
___ 06:25AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.2
___ 07:55AM BLOOD Albumin-2.6* Calcium-8.0* Mg-2.1
___: CXR:
No acute cardiopulmonary abnormality.
___: ERCP:
Successful ERCP with extraction of stone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROcodone-acetaminophen 7.5-325 mg oral Q4H:PRN
2. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
3. PredniSONE 10 mg PO DAILY:PRN shortness of breath
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
5. Omeprazole Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*12 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
6. Senna 8.6 mg PO BID:PRN Constipation - Second Line
7. Omeprazole 40 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
9. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
gallstone pancreatitis
choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: History: ___ with cholangitis*** WARNING *** Multiple patients
with same last name!// pre-op
TECHNIQUE: Upright AP view of the chest
COMPARISON: None.
FINDINGS:
Heart size is normal. Aortic knob is mildly calcified. Mediastinal and hilar
contours are normal. Lungs are hyperinflated with emphysematous changes noted
in the upper lobes. No focal consolidation, pleural effusion, or pneumothorax
is seen. Severe degenerative changes of the right glenohumeral joint are
noted. Narrowed acromial humeral intervals bilaterally suggest rotator cuff
disease. No acute osseous abnormality.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified jaundice, Right upper quadrant pain
temperature: 98.9
heartrate: 100.0
resprate: 16.0
o2sat: 95.0
sbp: 122.0
dbp: 80.0
level of pain: 7
level of acuity: 3.0 | ___ year old female admitted from an outside hospital with upper
abdominal pain. On review of imaging, she was found to have
gallstone pancreatitis and probable choledocholithiasis. She
was transferred here for ERCP which was done on HD #2. A
biliary sphincterotomy was done with the removal of pus, stones
and sludge. The patients liver function tests were monitored and
after they trended down, the patient was taken to the operating
room where she underwent a laparoscopic cholecystectomy.
The operative course was stable. The patient was extubated
after the procedure and monitored in the recovery room. The
patient resumed a regular diet and was voiding without
difficulty. Her incisional pain was controlled with oral
analgesia. The patient was discharged on a course of
ciprofloxacin. Discharge instructions were reviewd and
questions answered. A follow-up appointment was made in the
acute care clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Fragmin / Iodinated Contrast Media
Attending: ___
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female well known to
service that recently underwent coronary artery bypass graft
surgery x2 on ___ and was discharged home after
uneventful post op course. on ___ to home. She noted
yesterday
that after changing from sitting to standing position that she
had palpitations and heart rate on finger sat monitor that rate
120's, she laid down and heart rate slowed to 106 and
lightheadness resolved. She did okay over night but again this
after with position change noted that heart rate up to 130's
with
lightheadedness and palpitations. She was directed to take 6.25
mg Lopressor at home around 4pm and presented to the hospital
for
evaluation. Currently denies palpitations. Additionally notes
having dyspnea with activity but denies CP, Nausea, vomiting,
syncope.
Past Medical History:
Coronary artery disease s/p PCI
Deep Vein Thrombosis, ___
Iron Deficiency Anemia
Transient Ischemic Attack, ___
Myocardial Infarction ___
Prediabetes
Pulmonary nodule - Ultrasound negative
Social History:
___
Family History:
Grandmother CAD
Physical ___:
98.1- 114/76-107-18 100% Room air
General:
Skin: Dry intact
Neck: Supple Full ROM
Chest: Lungs clear bilaterally except decreased left base
Heart: RRR no murmur or rub
Abdomen: Soft non-distended non-tender bowel sounds + BM ___
Extremities: Warm well-perfused Edema none
Neuro: generalized weakness no focal deficits a/o x3
Pulses:
DP Right: P Left: P
___ Right: P Left: P
Radial Right: P Left: P
Pertinent Results:
___ ___ ___ ___
Radiology Report CHEST (PORTABLE AP) Study Date of ___
8:28 ___
___ CSURG FA8 ___ 8:28 ___
CHEST (PORTABLE AP) Clip # ___
Reason: eval etiology of SOB
UNDERLYING MEDICAL CONDITION:
___ year old woman with SOB
REASON FOR THIS EXAMINATION:
eval etiology of SOB
Final Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB // eval etiology of SOB
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is minimal left basilar atelectasis and unchanged
elevation of the left
hemidiaphragm. No focal consolidation, pleural effusion or
pneumothorax. The
median sternotomy wires are intact. The size of the cardiac
silhouette is
within normal limits.
IMPRESSION:
Unchanged elevation of the left hemidiaphragm with subjacent
atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
3. Famotidine 20 mg PO BID
4. Isosorbide Dinitrate 5 mg PO TID
5. TiCAGRELOR 90 mg PO BID
6. Metoprolol Tartrate 6.25 mg PO BID
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg one tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
2. Famotidine 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Isosorbide Dinitrate 5 mg PO TID
5. Rosuvastatin Calcium 20 mg PO QPM
6. TiCAGRELOR 90 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
palpitations
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No Edema
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB // eval etiology of SOB
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is minimal left basilar atelectasis and unchanged elevation of the left
hemidiaphragm. No focal consolidation, pleural effusion or pneumothorax. The
median sternotomy wires are intact. The size of the cardiac silhouette is
within normal limits.
IMPRESSION:
Unchanged elevation of the left hemidiaphragm with subjacent atelectasis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Tachycardia
Diagnosed with Tachycardia, unspecified
temperature: 98.1
heartrate: 107.0
resprate: 18.0
o2sat: 100.0
sbp: 114.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted for dyspnea on exertion and
palpitations. During her admission her Lopressor was increased
but she remained in sinus rhythm throughout. Her chest
radiograph did not reveal significant effusions and she remained
on room air with excellent oxygen saturation. Orthostatics were
negative. On hospital day two she was discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine / latex / Penicillins / ciprofloxacin
Attending: ___
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
___ - podiatry clipped a blister
History of Present Illness:
___ PMH ESRD on HD (missed last two appts), Linear Grade B
Esophagitis, CAD on Plavix/ASA, CHF, T2DM, HTN, HLD, ESRD on HD
(___), PVD with chronic non-healing left calcaneal ulcer
s/p
left ___ bypass c/b recurrent distal bypass graft stenosis
requiring yearly graft PTA p/w chest tightness which is
exacerbated/caused by persistent, productive cough and that is
occasionally accompanied by hemoptysis.
Prior to this admission, patient felt so unwell that he was
unable to make his two most recent hemodialysis appointments.
Endorses hiccups and epigastric/substernal CP that improves with
belching. The chest pain is pleuritic, non-radiating and
non-exertional. He also endorses dyspnea, DOE, nausea but no
vomiting. Denies fevers/chills, congestion, rhinorrhea,
abdominal
pain, diarrhea and constipation. No known sick contacts. No
recent travel, or prison time.
Notably, patient recently admitted ___, presenting
with cough, chest pain, and coffee ground emesis. This was felt
to represent food mixed with vomit i/s/o stable H/H. Felt most
likely recurrent esophagitis ___ gastroparesis or medication
non-compliance. He was treated with Reglan, PO PPI and patient's
nausea/vomiting improved.
In the ED:
Initial vital signs were notable for: 98.1 100 143/88 20 98%
RA
Labs were notable for:
- Trop 0.17 -> 0.17
- MB 2
- Flu negative
- Lactate 2.3
Studies performed include:
CXR
IMPRESSION:
No acute intrathoracic process.
CTA:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Diffuse esophageal wall thickening and adjacent fat
stranding
suggestive
of esophagitis. Per discussion with Dr. ___ patient
recently had an
endoscopy which demonstrated grade B esophagitis.
3. Trace right pleural effusion.
4. Mild cardiomegaly with left ventricular hypertrophy and
moderate coronary
artery calcifications.
EKG: Sinus rhythm at 102 with frequent PVCs, normal axis, normal
intervals, peaked T waves, no ST/T wave changes
Patient was given:
___ 15:00 IV Calcium Gluconate
___ 15:00 IV Insulin Regular 10 units
___ 15:00 IV Dextrose 50% 25 gm
___ 16:06 IV Calcium Gluconate 1 gm
___ 16:18 IVF NS Started 250 mL/hr
___ 17:43 IV CefTRIAXone 1 gm
___ 17:47 IV Azithromycin (500 mg ordered)
Consults: Renal, "Noted. Will assess in AM and plan for HD on
___ unless other acute issues arise."
Vitals on transfer: 98.5 102 162/78 18 99% RA
Upon arrival to the floor, patient corroborates above
information. Continued to have off and on chest pain that is
worse with deep breaths and improves with belching.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- Linear Grade B Esophagitis
- ESRD TTS ___
- DMII complicated by severe nonproliferative diabetic
retinopathy and chronic left heel ulcer
- Hypertension
- Hyperlipidemia
- Peripheral Vascular Disease s/p RLE angiogram with SFA stent
by Dr. ___ in ___, left femoral to posterior tibial artery
bypass with vein graft by Dr. ___ in ___ with balloon
angioplasty of vein graft stenosis in ___
- Chronic left heel ulceration complicated by wet gangrene in
___ requiring multiple debridements
- Chronic non-healing right heel s/p debridement of right heel
ulcer and removal of foreign body by Podiatry in ___
- Psoriatic Arthritis
- Osteoarthritis
Social History:
___
Family History:
Per prior discharge summary. Mother with diabetes, asthma, and
hypertension. Father with prostate cancer. Grandmother with
ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
==============================
VITALS: 98.3 | 170/85 | 91 | 19 | 95%Ra
General: ill appearing middle-aged male, actively coughing
without production
HEENT: NC, AT. Nares patent.
Chest: Decreased aeration throughout, no appreciable rales,
rhonchi or wheezes.
CV: RRR, ___ systolic murmur appreciated
Abdomen: Soft, non-tender, no HSM.
Ext: fistula with palpable thrill to left arm. Left heal ulcer
with various stages of healing, but no obvious signs of
infection; not warm to touch. Legs warm without edema.
Neuro: Gross non-focal, AOx3
DISCHARGE PHYSICAL EXAM
==============================
General: laying in bed, nontoxic, NAD.
HEENT: NC, AT. Moist mucous membranes.
Chest: Poor air movement but overall clear to auscultation.
CV: RRR, systolic murmur likely d/t fistula
Abdomen: Soft, non-tender, nondistended.
GU: No foley.
Ext: fistula with palpable thrill to left arm.
Neuro: Grossly non-focal. Moving all limbs ith purpose against
gravity.
Derm: B heel ulcers denuded but starting to heal
Pertinent Results:
ADMISSION LABS
===============================
___ 02:44PM BLOOD WBC-12.4* RBC-5.52 Hgb-13.9 Hct-44.7
MCV-81* MCH-25.2* MCHC-31.1* RDW-18.3* RDWSD-50.8* Plt ___
___ 02:44PM BLOOD Neuts-83.9* Lymphs-10.4* Monos-4.9*
Eos-0.3* Baso-0.2 Im ___ AbsNeut-10.35* AbsLymp-1.29
AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03
___ 02:44PM BLOOD Glucose-263* UreaN-64* Creat-12.4*#
Na-134* K-5.4 Cl-86* HCO3-20* AnGap-28*
___ 02:44PM BLOOD CK-MB-2 cTropnT-0.17*
___ 06:47PM BLOOD cTropnT-0.16*
___ 02:44PM BLOOD Calcium-9.1 Phos-7.9* Mg-2.7*
___ 02:58PM BLOOD Lactate-2.3* K-5.1
MICRO LABS
================================
___ 2:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:20 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0030.
GRAM POSITIVE COCCI IN CLUSTERS.
___ 02:53PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGING & STUDIES
=================================
___ CXR FINDINGS: AP upright and lateral views of the
chest provided. There is no focal consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal.
Atherosclerotic calcifications in the aortic knob are again
noted. No displaced fractures are seen.
IMPRESSION: No acute intrathoracic process.
___ CTA IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Diffuse esophageal wall thickening and adjacent fat
stranding suggestive of esophagitis. Per discussion with Dr.
___ patient recently had an endoscopy which demonstrated
grade B esophagitis.
3. Trace right pleural effusion.
4. Mild cardiomegaly with left ventricular hypertrophy and
moderate coronary artery calcifications.
DISCHARGE LABS
==================================
___ 11:10AM BLOOD WBC-6.8 RBC-4.35* Hgb-10.9* Hct-35.7*
MCV-82 MCH-25.1* MCHC-30.5* RDW-16.5* RDWSD-49.5* Plt ___
___ 07:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Gabapentin 100 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Doxazosin 6 mg PO 4X/WEEK (___)
7. CloNIDine 0.2 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
RX *calcium carbonate [Tums] 200 mg calcium (500 mg) 1 tablet(s)
by mouth 4 per day Disp #*120 Tablet Refills:*0
3. CARVedilol 25 mg PO BID
hold in AM on dialysis days
RX *carvedilol 25 mg 1 tablet(s) by mouth at bedtime Disp #*90
Tablet Refills:*0
RX *carvedilol 25 mg 1 tablet(s) by mouth 4x/week ___ Disp
#*48 Tablet Refills:*0
4. Glargine 12 Units Bedtime
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 12 Units before BED; Disp #*1 Syringe Refills:*0
5. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth qPM Disp #*90 Capsule Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*0
7. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 mL by mouth 4 a day Disp #*1
Package Refills:*1
8. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
9. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
10. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#ESOPHAGITIS
#ESRD on HD
#HYPERTENSION
Discharge Condition:
Mental Status: Clear and coherent, but with baseline learning
disability and distrust of "orientation" questions.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. (Supposed to use a
walker given foot wounds)
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough x 4 days in an HD patient.// PNA?
COMPARISON: Multiple prior chest radiographs dating back to ___.
FINDINGS:
AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Atherosclerotic calcifications in the
aortic knob are again noted. No displaced fractures are seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with cough and hemoptysis for 4 days.// PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 4.4 s, 34.6 cm; CTDIvol = 15.3 mGy (Body) DLP = 530.2
mGy-cm.
Total DLP (Body) = 535 mGy-cm.
COMPARISON: CTA torso dated ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Moderate atherosclerotic calcifications in the aortic
arch, coronary arteries and origins of the great vessels are noted. Heart is
mildly enlarged and there is mild left ventricular hypertrophy. Pericardium
and great vessels are otherwise unremarkable. No pericardial effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. The esophagus demonstrates
moderate diffuse circumferential thickening and edema with mild fat stranding.
PLEURAL SPACES: There is a tiny right pleural effusion. There is no
pneumothorax.
LUNGS/AIRWAYS: There is minimal compressive atelectasis in the right lower
lobe. Otherwise, the lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable aside from a
small hiatal hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
SOFT TISSUES: Re-demonstrated is mild bilateral gynecomastia.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Diffuse esophageal wall thickening and adjacent fat stranding suggestive
of esophagitis. Per discussion with Dr. ___ patient recently had an
endoscopy which demonstrated grade B esophagitis.
3. Trace right pleural effusion.
4. Mild cardiomegaly with left ventricular hypertrophy and moderate coronary
artery calcifications.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:44 pm, 5 minutes
after discovery of the findings.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Cough
Diagnosed with Cough, Shortness of breath, Chest pain, unspecified
temperature: 98.1
heartrate: 100.0
resprate: 20.0
o2sat: 98.0
sbp: 143.0
dbp: 88.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ PMH ESRD on HD (missed last two appts),
Linear Grade B Esophagitis, CAD on Plavix/ASA, CHF, T2DM, HTN,
HLD, ESRD on HD (___), PVD with chronic non-healing left
calcaneal ulcer s/p left ___ bypass c/b recurrent distal
bypass graft stenosis requiring yearly graft PTA who presented
pleuritic chest pain and productive cough of reddish sputum,
with negative CTA, negative cardiac workup, and ongoing pain
attributable to esophagitis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with history of GERD who
presents with diarrhea.
The patient was in her usual state of health until ___ around
midnight when she developed diarrhea associated with bloating
and nausea. She reports persistent symptoms since then. Stool is
described as mucousy with ocassional red clots of BRB. She
reports fevers and chills but denies vomiting or dysuria. Also
denies chest pain, shortness of breath, rashes, sick contacts or
recent travel. Of note, she had been taking bactrim on ___ &
___ (4 doses) for possible infected cut on right arm. She
reports eating fried clams for lunch on ___ and felt unwell
towards the end of her meal. She had normal colonoscopy in ___.
In the ED, initial VS: T- 100.5, HR- 94, BP- 129/50, RR- 18,
SaO2- 100% on RA. CT abd/pelvis consistent with colitis. She
received IV hydration, cipro, flagyl, zofran, morphine and
tylenol in the ED with good response. She is being admitted for
further evaluation. On transfer, vital signs were T- 97, HR-
100, RR- 18, BP- 137/67, SaO2- 100% on RA.
On arrival to the floor, vital signs were Temp 98.7F, BP 110/52,
HR 90, R 20, O2-sat 97% RA. Patient currently afebrile and
comfortable.
Past Medical History:
1. GERD
2. OSA
3. Seasonal allergies
Social History:
___
Family History:
No family history of inflammatory bowel disease or autoimmune
disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - Temp 98.7F, BP 110/52, HR 90, R 20, O2-sat 97% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, dry mucuous membranes, OP clear
NECK - Supple, no JVD,
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Mild tenderness in lower abdomen, positive bowel
sounds, soft, non-distended.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal
deficits, steady gait.
DISCHARGE PHYSICAL EXAM
VS: TEMP 98.1, BP 100/72, HR 73, RR 18, O2 sat 9% on RA
GENERAL: A & OX3, NAD
HEENT: PERRL, MMM, OP Clear
NECK: supple, JVD flat
HEART: RRR, nl S1, S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: Tenderness to palpation in lower abdomen, positive
bowel sounds, soft, non-distended, no hepatosplenomegaly
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses
LYMPH: no cervical LAD
Pertinent Results:
ADMISSION LABS
___ 07:30PM BLOOD WBC-17.1*# RBC-4.90 Hgb-14.4 Hct-41.5
MCV-85 MCH-29.4 MCHC-34.8 RDW-13.0 Plt ___
___ 07:30PM BLOOD Neuts-88.2* Lymphs-8.0* Monos-3.0 Eos-0.4
Baso-0.4
___ 07:30PM BLOOD Glucose-125* UreaN-11 Creat-1.0 Na-133
K-4.4 Cl-97 HCO3-20* AnGap-20
___ 07:30PM BLOOD Albumin-4.6 Calcium-8.9 Phos-2.2* Mg-2.0
___ 07:30PM BLOOD ALT-13 AST-32 AlkPhos-109* TotBili-0.4
DISCHARGE LABS
___ 06:25AM BLOOD WBC-8.6 RBC-3.80* Hgb-11.4* Hct-32.7*
MCV-86 MCH-29.9 MCHC-34.7 RDW-13.0 Plt ___
___ 06:25AM BLOOD Glucose-111* UreaN-6 Creat-0.8 Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
PERTINENT LABS
___ 07:38PM BLOOD Lactate-2.2*
___ 07:09AM BLOOD Lactate-0.8
MICROBIOLOGY
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Preliminary): Pending
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Blood Cx ___ X2: NGTD
Urine Cx: no growth
RADIOLOGY:
CT ABD/PELVIS (___)
IMPRESSION: Diffuse wall thickening and fat stranding
surrounding the distal transverse colon and proximal descending
colon, findings consistent with colitis. No evidence of adjacent
diverticula. No perforation or abscess formation.
Medications on Admission:
1. Omeprazole 40mg daily
2. Sertaline 100mg daily
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0*
6. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY
(Daily) as needed for hemorrhoidal pain.
Disp:*1 tubes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
C.diff colitis
Secondary diagnosis:
GERD
OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with abdominal pain, worse in the left lower
quadrant and bloody diarrhea.
COMPARISON: CT abdomen and pelvis from ___.
TECHNIQUE: ___ MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness. Intravenous contrast was
administered. Coronal and sagittal reformations were prepared.
FINDINGS: Lung bases are clear. There is no focal nodule, mass, or effusion.
The imaged cardiac apex is within normal limits.
The liver demonstrates homogeneous parenchymal enhancement without suspicious
focal lesion. The hepatic veins and portal venous system are grossly patent.
No intra- or extra-hepatic biliary ductal dilatation is identified. The
gallbladder, spleen, pancreas and adrenal glands are normal. There is
symmetric enhancement and excretion of the kidneys without suspicious focal
lesion or hydronephrosis. The abdominal aorta and its branch vessels are
non-aneurysmal and grossly patent. Surgical clips are seen at the level of
the ___ takeoff (2:46). Retroperitoneal surgical clips are also seen.
GI: The stomach and small bowel loops are normal in caliber and configuration
without evidence of obstruction or inflammation. The appendix is not clearly
visualized; however, there are no secondary signs of acute appendicitis.
There is diffuse wall thickening and stranding around the distal transverse
colon and proximal descending colon, findings consistent with colitis. No
free air is identified to suggest microperforation. There is no free fluid.
No diverticula are identified to suggest that this is related to acute
diverticulitis. No clear obstructing mass lesion is visualized within the
colon.
CT PELVIS WITH INTRAVENOUS CONTRAST: The uterus is not clearly visualized,
likely secondary to prior surgical resection. No adnexal mass lesion is
identified. The bladder is mildly distended and appears within normal limits.
There is no pelvic free fluid. No pathologically enlarged pelvic or inguinal
lymph nodes are identified. Multiple surgical clips are also seen within the
midline pelvis.
OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is
identified. Grade one anterolisthesis of L4 on L5 is stable.
IMPRESSION: Diffuse wall thickening and fat stranding surrounding the distal
transverse colon and proximal descending colon, findings consistent with
colitis. No evidence of adjacent diverticula. No perforation or abscess
formation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DIARRHEA
Diagnosed with ABDOMINAL PAIN LLQ, DIARRHEA, MELENA
temperature: 100.5
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 129.0
dbp: 50.0
level of pain: 6
level of acuity: 3.0 | ___ female with GERD presented with diarrhea and abdominal
cramping, and was found to have C.diff colitis.
ACTIVE ISSUES
# C.diff colitis: Pt's C.diff developed in the setting of
chronic PPI use, recent ABx (Clindamycin & bactrim) in past
three weeks. She underwent CT abd/pelvis since admission, and
was found to have diffuse wall thickening surrounding distal
transverse colon and proximal descending colon. Her C.diff
toxin screening was positive. Pt was treated with metronidazole
initially iv, later switched to po, given her lack of
comorbidities and first presentation. Her diarrhea started to
abate on HD #3. Pt tolerated po diet well prior to discharge
from the hospital. Plan is to complete 14 days of metronidazole
from discontinuation of ciprofloxacin.
# Rash: pt developed tiny bustules along hair follicles along
the waistband of her underwear area and anterior abdomen on
HD#3. The rash was stable in the next ___ hours while she was in
the hospital. We felt the rash was most likely secondary to
folliculitis and not consistent with drug rash so did not change
antibiotic regimen.
CHRONIC ISSUES
# GERD: We continued her home omeprazole at 40 mg qd. However,
PPI use is associated with increased risk of C.diff colitis, and
would recommend re-evaluate for the indication for current
regimen.
# OSA: We continued her home CPAP.
TRANSITIONAL ISSUES
# CODE STATUS: Full (confirmed)
# PENDING STUDIES ON DISCHARGE:
- Stool O&P on ___
- blood culture on ___
# MEDICATION CHANGES
- Flagyl 500 mg q8 hour for 2 weeks
# FOLLOW UP PLAN
- Appt with PCP ___ ___
- Pt may need switch of antibiotics if rash worsens |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx significant for extensive atherosclerosis disease
including CAD s/p CABG x2, stent, ___ CEA, HTN, T2DM, and
Alzheimers dementia presenting status post fall.
Patient is a poor historian at baseline and lives alone at
assisted living facility. Per patient report, he fell 1x
yesterday and then again today. Today he was trying to maneuver
between the sink and the toilet in the
bathroom when he fell. "I just lost my balance." He reports some
lightheadedness and dizziness but denies any aura, no LOC, no
urinary or fecal incontinance. He can't remember how long it
took
him to hoist himself up off the ground but thinks it was
probably a while. He lives alone, in independent living and the
fall was unwitnessed. He otherwise denies any chest pain,
shortness of breath. No fevers or chills. Per ED, "patient is
pleasant but unclear how reliable he is for a history." Of
note, patient had an admission for fall in ___ where
he sustained right ___ rib fractures.
In the ED, initial VS were: 99.6, 105, 149/86, 16, 93% RA
Exam notable for:
Mental Status: a&ox2, disoriented to date and place, confused at
times, calm, cooperative and pleasant
Ecchymosis on arms and legs however non-tender. Unremarkable
exam.
Labs showed:
- CBC: 10.5/11.9/39.7/190
- Chem7: K 4.5, Cr 1.1
- CK 492
- Trp T: 0.31
Imaging showed:
- CT C-spine: No fracture or malalignment, multilevel
multifactorial degenerative changes
- CT Head: No acute process
- CXR: Left base retrocardiac opacity raises concern for
pneumonia or aspiration. Bilateral pleural effusions.
Re-demonstrated fracture of the anterolateral right seventh rib.
Received:
___ 17:16 IVF NS
___ 18:01 IV Heparin bolus & gtt
___ 18:06 PO Aspirin 243 mg
___ 21:28 PO/NG Clopidogrel 75 mg
___ 21:29 PO Metoprolol Succinate XL 50 mg
___ 21:29 PO/NG Furosemide 20 mg
On arrival to the floor, patient is resting. he gives the
history as above. Endorses a cough, only coughing up phlegm. No
fever, chills, no chest pain.
Past Medical History:
CAD s/p CABG ___ ___ in ___) s/p cardiac
stents ___ s/p CABG ___ ___ in ___.)
DMII
HTN
Carotidendarterectomy in ___ (R) and ___ (L)
Mild CRI (Cr 1.5-1.8)
Anemia
Eczema
BPH
Social History:
___
Family History:
Mother - MI at age of ___
Father - brain tumor
Brother - ___ MI at age ___
Brother - kidney failure
Physical Exam:
ADMISSION EXAM:
=============
VS: 97.6, 157/85, 93 20 94 RA 64.5kg
GENERAL: NAD, AOx2 (to name and place, not year)
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, prominent carotid pulsation, JVP to mid neck at 30
degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Coarse crackles diffusely with decreased breath sounds at
Left base.
ABDOMEN: nondistended, nontender in all quadrants, +BS, no
rebound/guarding
EXTREMITIES: cool to mid shin, 2+ pitting edema bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2, strength ___ throughout non focal.
SKIN: scattered ecchymosis and superficial skin ulcerations on
back buttocks and extremities, 2x sacral ulcerations.
DISCHARGE EXAM:
==============
Vitals: 97.6 157 / 66 77 19 94 RA 62.4kg
General: elderly man, in NAD, resting supine comfortably;
oriented to self, year is ___, ___
HEENT: Sclerae anicteric, OP clear, hematoma on scalp
Neck: JVP not significantly elevated
Lungs: Normal WOB, lungs with basilar crackles
CV: RRR, S1/S2, no m/r/g
Abdomen: soft, NT/ND
Ext: warm, well perfused, no edema
SKIN: scattered ecchymosis and superficial skin ulcerations on
back buttocks and extremities, 2x sacral ulcerations.
Pertinent Results:
ADMISSION LABS:
=============
___ 04:08PM BLOOD WBC-10.5*# RBC-4.72 Hgb-11.9* Hct-39.7*
MCV-84 MCH-25.2* MCHC-30.0* RDW-16.2* RDWSD-49.8* Plt ___
___ 03:26AM BLOOD ___ PTT-40.0* ___
___ 04:08PM BLOOD Glucose-131* UreaN-30* Creat-1.1 Na-141
K-4.5 Cl-101 HCO3-23 AnGap-17*
___ 04:08PM BLOOD ___
___ 04:08PM BLOOD cTropnT-0.31*
___ 11:27PM BLOOD CK-MB-11* cTropnT-0.39*
___ 03:26AM BLOOD ALT-15 AST-32 AlkPhos-100 TotBili-1.0
___ 03:26AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.8
INTERVAL LABS:
============
___ 03:26AM BLOOD CK-MB-10 cTropnT-0.39*
___ 10:18AM BLOOD CK-MB-7 cTropnT-0.32*
DISCHARGE LABS:
=============
___ 06:25AM BLOOD WBC-7.8 RBC-4.41* Hgb-11.0* Hct-36.8*
MCV-83 MCH-24.9* MCHC-29.9* RDW-16.4* RDWSD-49.7* Plt ___
___ 06:25AM BLOOD Glucose-118* UreaN-33* Creat-1.0 Na-143
K-4.5 Cl-104 HCO3-25 AnGap-14
___ 06:25AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.1
REPORTS:
=======
CXR ___
Left base retrocardiac opacity raises concern for pneumonia or
aspiration. Bilateral pleural effusions. Re-demonstrated
fracture of the anterolateral right seventh rib.
CT HEAD ___. Small posterior scalp hematoma without underlying fracture.
2. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Finasteride 5 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Sertraline 25 mg PO DAILY
10. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Sertraline 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Community Acquired Pneumonia
Type II NSTEMI
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
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cough and s/p fall// ?pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and CABG. The cardiac and
mediastinal silhouettes are stable with the cardiac silhouette mild to
moderately enlarged. There is persistent blunting of the bilateral posterior
costophrenic angles suggesting small pleural effusions. In addition, there is
retrocardiac left base opacity raising concern for pneumonia or aspiration.
Fracture of the lateral right ninth rib is re-demonstrated. No definite
additional rib fracture is seen, but bones are osteopenic and chest
radiography has low sensitivity for the detection of such.
IMPRESSION:
Left base retrocardiac opacity raises concern for pneumonia or aspiration.
Bilateral pleural effusions. Re-demonstrated fracture of the anterolateral
right seventh rib.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with s/p fall unwitnessed and on plavix// ?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) = 1,304 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage,edema, or
mass. Subcortical, deep, and periventricular white matter hypodensities are
nonspecific, but likely represent the sequela of chronic microvascular
ischemic disease. There is prominence of the ventricles and sulci suggestive
of involutional changes. Dense atherosclerotic calcifications are noted
within the cavernous carotid arteries.
There is no evidence of fracture. Mucous retention cyst within the right
maxillary sinus. Mild mucosal thickening within the left maxillary sinus and
bilateral ethmoid air cells. Soft tissue within the bilateral ear canals
likely represents cerumen. The mastoid air cells and middle ear cavities are
clear. Patient is status post bilateral lens resections. Otherwise, the
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of fracture or intracranial hemorrhage.
2. Mild paranasal sinus disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with s/p fall// ?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: Total DLP (Body) = 506 mGy-cm.
COMPARISON: CT C-spine dated ___.
FINDINGS:
Posterior offset of C1 on C2 on the right is unchanged compared to ___, likely degenerative in nature (series 602, image 24). Mild
anterolisthesis of C3 on C4 is also unchanged and likely degenerative.
Otherwise, alignment is normal. No fractures are identified.There is no
prevertebral soft tissue swelling. There is no evidence of infection or
neoplasm.
Multilevel degenerative disc disease throughout the the cervical spine, most
severe at C5-6 and C6-7. Posterior intervertebral osteophytes cause
mild-to-moderate narrowing of the spinal canal, most severe at C5-6 (series 2,
image 43). There is also multilevel neural foraminal stenosis due to a
combination of uncovertebral and facet osteophytes, also most severe at C5-6.
The lung apices are clear. No cervical lymphadenopathy. No large thyroid
nodules.
IMPRESSION:
1. No evidence of fracture or traumatic malalignment. Posterior offset of C1
on C2 on the right is unchanged compared to ___, likely degenerative
in nature. Mild anterolisthesis of C3 on C4 is also unchanged and likely
degenerative.
2. Multilevel multifactorial degenerative changes, most severe at C5-6 with
moderate spinal canal stenosis and severe bilateral neural foraminal stenosis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with NSTEMI on heparin gtt, found to have fallen
out of bed by RN staff, with large hematoma on posterior head. AOx2 at prior
baseline, non focal neurologic examination// Evaluation for IC hemorrhage
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 18.0 s, 18.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 5.0 s, 10.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
501.7 mGy-cm.
Total DLP (Head) = 1,405 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of acute large territory infarct, hemorrhage, edema, or
mass. The ventricles and sulci are prominent compatible with age related
involutional changes. Periventricular and subcortical white matter
hypodensities are nonspecific, but likely reflect sequelae of chronic small
vessel ischemic disease.
There is a small posterior scalp hematoma without underlying fracture. A
mucous retention cyst is visualized in the right maxillary sinus. There is
mild mucosal thickening left maxillary sinus and ethmoid air cells. Otherwise
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
1. Small posterior scalp hematoma without underlying fracture.
2. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territory infarct or intracranial hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Weakness
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Fall on same level, unspecified, initial encounter
temperature: 99.6
heartrate: 105.0
resprate: 16.0
o2sat: 93.0
sbp: 149.0
dbp: 86.0
level of pain: 5
level of acuity: 2.0 | ___ with Alzheimer's disease, CAD, HFpEF, who presented with a
fall, found to have a Type II NSTEMI and Pneumonia.
# Community Acquired PNA: Presented with mild leukocytosis and
respiratory symptoms, with convincing imaging evidence of PNA.
Therapy complicated by allergy to both quinolone and
penicillins. Initially started on Azithromycin ___ and
Aztreonam given allergies. Ultimately received 5 day course of
therapy with Azithromycin, last day ___.
# ___ on CKD: Peak Cr of 1.5, from 1.1 on admission after
receiving IV diuretics for suspected volume overload. Diuretics
subsequently held, he remained euvolemic, and his Cr returned to
baseline ~1.
# Falls: Second fall in the last year. No obvious cardiac
etiology, though PNA could certainly have triggered a fall.
Patient is severely frail. Discontinued metoprolol, flomax, and
plavix. Discharged to rehab following ___ evaluation.
# Sacral Ulcer: Will need continued close wound care and
nutritional optimization.
# Swallowing: S+S team recommended nectar prethickened liquids
and video swallow study. After discussion with family, decided
to forgo plans for video swallow as family would like to
optimize PO nutrition for patient. Family is aware of aspiration
risk. Discharged on thin liquid and dysphagia diet.
# Type II NSTEMI
# History of CAD:
Likely demand ischemia in setting of fall and PNA. No complaint
of chest pain or concerning EKG changes. Briefly on heparin
drip, but was discontinued. Not a candidate for cath per
Cardiology evaluation. Medical management was advised but
Plavix and metoprolol were discontinued given risk from falls.
Statin was also discontinued. Continue aspirin.
# HFpEF:
Admitted with elevated BNP, with some JVD elevation on admission
exam. Received IV diuretics early on in admission, but Cr
increased quickly peaked to 1.5 with this. Maintained euvolemia
without diuretics for days prior to discharge so lasix was
discontinued.
# BPH: Continued on finasteride. Discontinued flomax.
# Mood: Continued on sertralin.
TRANSITIONAL ISSUES
======================
- Antibiotics course: finished ___ Azithromcyin
for CA-PNA.
- Wound care assessment:
-- Coccyx/sacral deep tissue pressure injury 2x0.5cm
-- Left glut full thickness stage 3 pressure injury 1x~0.2cm
-- Right elbow, partial thickness traumatic ulcer 1 x 0.5cm
-- Left elbow traumatic full tissue flap, skin tear 2 x 2.5 cm
-- Right knee traumatic ulcer ~ 2 x 1 cm
Apply commercial wound cleanser or normal saline to cleanse
wounds. Pat the tissue dry with dry gauze.
Apply moisture barrier ointment to the periwound tissue with
each dressing change. Apply xeroform to elbows, cover with ABD
pad, secure with kling wrap. To right knee, cover with Adaptic
gauze and secure with Kling change daily. Continue Mepilex
Sacral Border dressing to coccyx and change q 3 days. To left
glut continue Mepilex 4 x 4 and change q 3 days. Please offload
heels as he is at risk for developing pressure injury.
- Discharge diet: thin liquids, soft dysphagia diet
#CODE: DNR/DNI confirmed
#CONTACT: ___ ___ SON , ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Jaw pain s/p fall
Major Surgical or Invasive Procedure:
Open Reduction Internal Fixation of compound symphysis fracture
and closed reduction with maxillomandibular fixation of right
condylar fracture of mandible
History of Present Illness:
___ presenting after 15 foot fall while climbing down a water
tower. Patient reports that he slipped from the ladder and
landed on his feet then onto his chin. Denies LOC. Presented to
OSH and was transferred to ___ after Dx of mandibular fracture
and receiving Unasyn.
Upon arrival, patient reported jaw pain and malocclusion. No
chest pain or SOB. No fevers or chills. No nausea or vomiting.
No weakness, numbness or tingling.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: Comfortable, AAOx3
HEENT: Normocephalic, atraumatic, PERRL, EOMI. No midface
tenderness.
4 cm chin laceration with good approximation, oozing, sutures
have been removed. Patient in maxillomandibular fixation.
CV: RRR S1 and S2 without murmurs rubs or gallops
Abd: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema. Posterior tibial
pulses 2+ bilaterally
Neuro: Speech fluent. CN II-XII intact bilaterally. Strength and
sensation intact bilaterally
Pertinent Results:
___ 05:10AM BLOOD WBC-6.8 RBC-4.87 Hgb-14.2 Hct-42.9 MCV-88
MCH-29.2 MCHC-33.1 RDW-13.6 Plt ___
___ 05:10AM BLOOD Glucose-99 UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-101 HCO3-29 AnGap-15
Medications on Admission:
None
Discharge Medications:
1. Bacitracin Ointment 1 Appl TP QID
RX *bacitracin zinc 500 unit/gram apply to chin laceration four
times per day Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % swish in mouth twice per day
Refills:*0
3. Ibuprofen Suspension 600 mg PO Q8H:PRN pain Duration: 2 Weeks
RX *ibuprofen 100 mg/5 mL 30 mL by mouth every six (6) hours
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mandibular Fractures
Discharge Condition:
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fall with mandible fracture // eval for
surgical planning
TECHNIQUE: 2 PANOREX VIEWS
COMPARISON: Reference made to CT maxillofacial from outside institution
performed on ___ at 23:50.
FINDINGS:
Some patient motion makes examination suboptimal. The comminuted, displaced
superior right mandibular fracture is not included on the image. The
parasymphyseal mandibular fracture was better assessed on preceding CT. The
fracture appears to extend between the 2 central incisors. Better seen on CT,
the right lateral incisor appears decreased in height as compared to the
adjacent right central incisor and adjacent left right canine. The left
lateral incisor appears somewhat angulated. Fracture of a right-sided
mandibular molar was better seen on CT.
Radiology Report
HISTORY: Jaw fracture, status post ORIF and CRIF, evaluate alignment.
PANOREX, ONE VIEW. MANDIBLE, FOUR VIEWS
The patient's mouth appears to have been wired shut. Two screws extend across
the parasymphyseal portion of the mandible. No displaced fracture is detected
on these views. A known sagittal midline fracture through the midline mental
portion of the mandible is not well appreciated radiographically, likely due
to close apposition of the fracture fragments as well as technical
limitations.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MANDIBULAR FX
Diagnosed with MULT FX MANDIBLE-CLOSED, TOOTH (BROKEN) (FRACTURED) (DUE TO TRAUMA), WITHOUT MENTION OF COMPLICATION, OPEN WOUND OF JAW, FALL-1 LEVEL TO OTH NEC
temperature: 99.0
heartrate: 78.0
resprate: 16.0
o2sat: 98.0
sbp: 125.0
dbp: 59.0
level of pain: 4
level of acuity: 3.0 | Patient was admitted to the Acute Care Surgery service for pain
control, IV antibiotics and with plan for operative management
of mandibular fractures. Patient did well after admission; his
pain was controlled and vitals and lab tests remained stable. A
tertiary survey did not demonstrate any other injuries. Patient
was taken to the Operating Room on HD 2 by ___ where he
received Open reduction internal fixation of symphysis fracture
a closed reduction of right condylar fracture and
maxillomandibular fixation. He tolerated the procedure well and
was stable postoperatively. IV antibiotics were continued until
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
nausea/vomiting and watery diarrhea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
History of Present Illness: ___ YO gentleman presenting with one
day of nausea and vommiting. History is obtained from patient
and supplemented by ED records as patient is not too verbose
this evening. He apparently ate some chicken this afternoon and
had episodes of nausea vommiting and diarrhea. He is unable to
quantify how frequently he is having bowel movements but he had
2 bowel movements over the course of one hour while admitting
him. These stools are watery and of moderate volume. No frank
blood by nursing report. He denies fevers and also denies seeing
blood. Unclear if there are sick contacts.
.
On the floor, he is lying in the fetal postions and answering
questiosn appropriatly but very brief one to three word answers.
He refuses to lay on his back for the exam. Endorses thirst and
is activly stooling. No vommiting since being in the ED.
.
Review of systems:
(+) Per HPI
Past Medical History:
1. ___ years
2. Diabetes ___ years
3. TIAs
4. Renal insufficiency- Most recent BUN/CRE= 39/1.5
5. Anemia-
6. Pulmonary nodules
7. Hyperuricemia
8. Cerebrovascular disease
9. Diverticulitis
10. Prostatectomy
11. Glaucoma
Social History:
___
Family History:
His son has a cardiomyopathy. His sister died of lung cancer
Physical Exam:
Admission Physical Exam:
Vitals: 98.6 156/67 108 20 99 3L
Physical exam is compromised by patient lying on side and
actively stooling during entire duration of exam.
General: Alert, oriented, answers questions appropriately
HEENT: dry MM
Neck: unable to assess
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely TTP throughout
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
Vitals: 97.8 121/71 82 22 97RA
General: alert, oriented x3, NAD
HEENT: NCAT, EOMI, PERRL, dry MM
NECK: no palpable lymphadenopathy, JVP to 9cm
___: RRR, normal s1,s2, no murmurs rubs gallops
Lungs: Patient breathing comfortably room air at rest. Right
basilar inspiratory crackles. Otherwise clear to auscultation,
no wheezing.
Abdomen: Obese, soft, non distended, non tender, +BS
Ext: wwp, 2+ pulses, no LLE
Skin: no rashes
Pertinent Results:
ADMISSION LaBS:
___ 08:45PM BLOOD WBC-9.7 RBC-4.67 Hgb-14.5 Hct-43.8 MCV-94
MCH-31.2 MCHC-33.2 RDW-15.7* Plt ___
___ 08:45PM BLOOD Neuts-87.6* Lymphs-4.9* Monos-4.6 Eos-2.7
Baso-0.2
___ 08:45PM BLOOD Glucose-199* UreaN-48* Creat-1.8* Na-145
K-4.0 Cl-106 HCO3-23 AnGap-20
___ 08:45PM BLOOD ALT-28 AST-37 AlkPhos-102 TotBili-0.4
___ 08:45PM BLOOD Albumin-4.6
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-6.5 RBC-4.07* Hgb-12.7* Hct-37.8*
MCV-93 MCH-31.1 MCHC-33.5 RDW-16.2* Plt ___
___ 10:15AM BLOOD Neuts-72.9* Lymphs-15.8* Monos-8.1
Eos-2.9 Baso-0.3
___ 07:05AM BLOOD Glucose-136* UreaN-28* Creat-1.3* Na-145
K-3.5 Cl-109* HCO3-26 AnGap-14
___ 07:05AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.9 Iron-59
___ 07:05AM BLOOD calTIBC-265 VitB12-663 Folate-GREATER TH
Ferritn-176 TRF-204
___ 10:15AM BLOOD LEGIONELLA PNEUMOPHILA ANTIBODY-PND
ECG ___ 10:33:38 ___
Baseline artifact makes interpretation difficult. Repeat tracing
is suggested. Probable sinus rhythm with ventricular premature
beats. Compared to the previous tracing of ___ artifact is
new, ventricular rate is faster.
IntervalsAxes
___
___
CXR ___:
IMPRESSION: Bibasilar atelectasis and low lung volumes. While
ther is no overt evidence of pneumonia, a retrocardiac opacity
in the appropriate clinical setting may be an early infectious
process.
CXR ___: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Unchanged low lung volumes with
areas of atelectasis at both lung bases. No interval appearance
of pneumonia. No pleural effusions. Unchanged left pectoral
pacemaker, unchanged borderline size of the cardiac silhouette,
without pulmonary edema.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing
2. Allopurinol ___ mg PO DAILY
3. Bumetanide 4 mg PO DAILY
hold for SBP<100
4. FoLIC Acid 1 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES Frequency is
Unknown
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<100 or hr<50
10. Pregabalin 200 mg PO DAILY
11. Simvastatin 40 mg PO DAILY
12. Timolol Maleate 0.25% 1 DROP RIGHT EYE BID
13. Valsartan 80 mg PO DAILY
hold for sbp<100
14. Ambien CR *NF* (zolpidem) 10 mg Oral QHS
15. Aspirin 325 mg PO DAILY
16. coenzyme Q10 *NF* 100 mg Oral unknown
17. Pyridoxine 25 mg PO DAILY
Discharge Medications:
1. GlipiZIDE 10 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<100 or hr<50
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing
4. Allopurinol ___ mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Bumetanide 4 mg PO DAILY
hold for SBP<100
7. FoLIC Acid 1 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Pregabalin 200 mg PO DAILY
11. Pyridoxine 25 mg PO DAILY
12. Simvastatin 40 mg PO DAILY
13. Timolol Maleate 0.25% 1 DROP RIGHT EYE BID
14. Valsartan 80 mg PO DAILY
hold for sbp<100
15. coenzyme Q10 *NF* 100 mg Oral unknown
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
17. Ambien CR *NF* (zolpidem) 10 mg Oral QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with increased respiratory failure. Question
pneumonia.
COMPARISON: ___.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS: There are low lung volumes which accentuates bibasilar atelectasis.
Cardiomediastinal silhouette and hilar contours are unremarkable. A battery
pack with pacemaker leads terminating in the right atrium and right ventricle
are in unchanged position. A slight increase in the retrocardiac density may
be due to low lung volumes versus early infectious process.
IMPRESSION: Bibasilar atelectasis and low lung volumes. While ther is no overt
evidence of pneumonia, a retrocardiac opacity in the appropriate clinical
setting may be an early infectious process.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dyspnea on exertion, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is no relevant
change. Unchanged low lung volumes with areas of atelectasis at both lung
bases. No interval appearance of pneumonia. No pleural effusions. Unchanged
left pectoral pacemaker, unchanged borderline size of the cardiac silhouette,
without pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: VOMITING AND/OR NAUSEA
Diagnosed with NONINF GASTROENTERIT NEC
temperature: 97.9
heartrate: 94.0
resprate: 26.0
o2sat: 95.0
sbp: 149.0
dbp: 54.0
level of pain: 0
level of acuity: 3.0 | ___ w/ PMH significant for anemia, CHF with preserved EF who
presented with nausea/vomiting and watery diarrhea for 24 hours. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLQ pain, N/V, chills and dysuria found to have 3mm stone and
hydronephrosis on CT.
Major Surgical or Invasive Procedure:
PROCEDURE: Cystoscopy, right retrograde pyelogram, right
ureteral stent placement.
History of Present Illness:
___ presenting for the third time with RLQ pain, N/V, chills and
dysuria found to have 3mm stone and hydronephrosis on CT.
Past Medical History:
Nephrolithiasis
___, Right Retrograde Pyelogram, Right Ureteral
Stent PlacementCarrasquillo
___ REDUCTION PERCUTANEOUS PINNING RIGHT ___
METACARPALRozental
Social History:
___
Family History:
Daughter with nephrolithiasis
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
IUC has been removed. He is voiding.
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 06:50AM BLOOD WBC-8.0 RBC-4.12* Hgb-12.2* Hct-35.8*
MCV-87 MCH-29.6 MCHC-34.1 RDW-12.4 RDWSD-39.9 Plt ___
___ 03:08PM BLOOD WBC-11.7* RBC-4.42* Hgb-12.9* Hct-38.3*
MCV-87 MCH-29.2 MCHC-33.7 RDW-12.4 RDWSD-39.6 Plt ___
___ 03:08PM BLOOD Neuts-82.4* Lymphs-7.8* Monos-9.0
Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.67* AbsLymp-0.92*
AbsMono-1.05* AbsEos-0.01* AbsBaso-0.03
___ 06:50AM BLOOD Glucose-83 UreaN-11 Creat-1.3* Na-141
K-4.1 Cl-102 HCO3-28 AnGap-11
___ 03:08PM BLOOD Glucose-88 UreaN-11 Creat-1.5* Na-137
K-4.4 Cl-100 HCO3-24 AnGap-13
___ 10:04 pm URINE Site: CYSTOSCOPY RIGHT RENAL
URINE.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:13 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
2. 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
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by
Acetaminophen
RX *ibuprofen 600 mg ONE tablet(s) by mouth Q6hrs Disp #*25
Tablet Refills:*0
4. Phenazopyridine 100 mg PO TID:PRN burning with urination
Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg ONE tablet(s) by mouth
q8hrs Disp #*9 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily
Disp #*21 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
nephrolithiasis; Right ureteral stone with obstruction
Acute kidney injury
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: +PO contrast; History: ___ hx nephrolithiasis with 5d RLQ pain
and fever+PO contrast// ?appendicitis vs renal calculus or urinary tract
obstruction
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 6.6 s, 51.6 cm; CTDIvol = 9.5 mGy (Body) DLP = 491.6
mGy-cm.
Total DLP (Body) = 500 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
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: Right kidney is enlarged with delayed nephrogram and there is
moderate right hydroureteronephrosis secondary to an obstructing right distal
ureteral calculus, just proximal to the ureterovesical junction measuring 3
mm. Additionally, perinephric and periureteral fluid and stranding suggest
possible forniceal rupture. The left kidney enhances normally with
subcentimeter hypodensity in the upper pole, too small to fully characterize,
but likely a cyst. There is no left-sided hydronephrosis in the left ureter
appears unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: There is moderate right hydroureteronephrosis with periureteral
stranding due to an obstructing 3 mm right distal ureteral calculus, just
proximal to the ureterovesical junction. The urinary bladder and distal left
ureter are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: Curvilinear area of subchondral sclerosis in the left femoral head
suggest avascular necrosis without evidence for femoral head collapse. There
is no evidence of worrisome osseous lesions or additional fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Obstructing 3 mm right distal ureteral calculus, just proximal to the
ureterovesical junction, resulting in upstream moderate right
hydroureteronephrosis. Right-side perinephric and periureteral fluid and
stranding suggest possible forniceal rupture. Please note that infection of
the right collecting system is also not excluded, and correlation with
urinalysis is needed.
2. Left femoral head avascular necrosis without evidence for femoral head
collapse.
3. Normal appendix.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY) IN O.R.
INDICATION: Intraoperative abdominal radiographs
TECHNIQUE: Intraoperative abdominal radiographs were obtained.
Total fluoro time is 17.9 seconds.
Cumulative Dose: 4.11 mGy.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
Intraoperative images were acquired without a radiologist present. Please see
operative note for further details of the procedures.
Images show intra-abdominal contrast injection through a right ureteral stent.
IMPRESSION:
Intraoperative images were obtained. Please refer to the operative note for
details of the procedure.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Calculus of ureter, Urinary tract infection, site not specified, Right lower quadrant pain
temperature: 101.1
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 160.0
dbp: 91.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ presents with right ureteral stone and obstruction so
he was admitted to urology for nephrolithiasis management. He
was taken urgently to the operative theatre where he underwent
cystoscopy, right retrograde pyelogram, right
ureteral stent placement. He tolerated the procedure well and
recovered in the PACU before transfer to the general surgical
floor. See the dictated operative note for full details.
Overnight, the patient was hydrated with intravenous fluids and
received appropriate perioperative prophylactic antibiotics. On
POD1, catheter was removed. Intravenous fluids and Flomax were
given to help facilitate passage of stones. At discharge on
POD1, patients pain was controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty. Patient was explicitly advised to
follow up as directed as the indwelling ureteral stent must be
removed and or exchanged and definitive stone management
addressed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old lady with a history of htn, family hx of
cad, and anxiety who presents with a 1 week history of worsening
dyspnea on exertion prompting diagnosis of bilateral PEs in the
___ ED.
She reports a the gradual onset of SOB 1 week prior associated
w/ progressive DOE, fatigue. For the past three days she had
several days of RUQ pain that radiated to the back was
unrelieved by position, food or rest. Prior to onset of sx she
reports a sedentary holiday break where she spent the majority
of the time on the couch, which is not atypical from usual
except that it was not interrupted by periods of work as ___ ___
___. She denies CP, palpitations, diaphoresis. No family or
personal history of blood clot or miscarriages. She is not
taking any estrogen containing medications. She has not smoked
tobacco since ___. She is not up to date on her routine cancer
screening, last mammogram > ___ years ago, PAP negative in ___
and no colonscopy. Her abdominal pain has resolved since
yesterday.
In the ED, initial VS were: 97.9 98 129/68 20 91% ra. Chem 7
notable for Ca ___. ALT/AST 51/62, AP 110, Lipase 22. D dimer
was 5240 and BNP was 105. White count was 11.1. CTA chest
demonstrated bilat lobar and segmental PE with equivocal CT
signs of rt heart strain and no infarct. RUQ US showed fatty
liver as well as cholelithiasis without cholecystitis. CXR
showed no acute cardiopulmonary process. EKG was negative for
RHS pattern but showed lateral ST depressions. Trop was
negative. Cardiology was consulted and performed a bedside TTE
which showed right ventricular mid-free wall akinesia with
normal apical motion. She was given aspirin and started on a
heparin gtt. Admission to the medical ICU was requested given
evidence of right heart strain.
On arrival to the MICU, her VS were: 109 140/74 92% on 3L NC.
She was comfortable and in NAD.
Past Medical History:
1. Obesity
2. Tobacco use
3. Positive PPD in ___, received ___ year ING
4. Esophageal Reflux
5. Anxiety
6. Hypertension
7. Irritable Bowel Syndrome
Social History:
___
Family History:
No family hx of DVT or PE
Physical Exam:
Admission:
Vitals: 109 140/74 92% on 3L NC.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated but compromised exam somewhat by
obesity
CV: Regular rate and rhythm, tachycardic without murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese nontender
GU: no foley
Ext: warm, well perfused, calves are symmetric w/out erythema or
swelling or tenderness to exam, no cords palpated
Discharge:
AVSS, on RA
Not otherwise changed
Pertinent Results:
___ 03:30PM BLOOD WBC-11.1* RBC-5.08 Hgb-15.5 Hct-45.2
MCV-89 MCH-30.5 MCHC-34.3 RDW-12.7 Plt ___
___ 06:25AM BLOOD WBC-9.0 RBC-4.44 Hgb-13.7 Hct-40.7 MCV-92
MCH-31.0 MCHC-33.7 RDW-13.0 Plt ___
___ 06:35AM BLOOD ___
___ 06:25AM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-138
K-3.4 Cl-102 HCO3-26 AnGap-13
___ 03:30PM BLOOD ALT-51* AST-62* AlkPhos-110* TotBili-0.7
___ 03:30PM BLOOD D-Dimer-5240*
TTE: The left ventricle is not well seen. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The right ventricle has akinesis of the mid-free
wall and normal motion of the apex ___ sign). The
aortic valve is not well seen. The mitral valve leaflets are not
well seen. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Right ventricular mid-free wall akinesia with normal
apical motion ___ sign) consistent with acute pulmonary
embolism. Due to the patient's habitus, this was a suboptimal
and technically difficult study.
CTA: IMPRESSION: 1. Bilateral lower lobar and segmental
pulmonary emboli with equivocal CT evidence for right heart
strain. 2. No signs of pulmonary infarction. 3. Fatty liver
with cholelithiasis.
Medications on Admission:
1. Omeprazole 20mg daily
2. Sertraline 50mg daily
3. Aspirin 81 mg daily
4. Alprazolam 1mg tid
5. Hydrochlorothiazide 25mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
do not take more than 4g per day
2. Aspirin 81 mg PO DAILY
3. Enoxaparin Sodium 130 mg SC Q12H
RX *enoxaparin 150 mg/mL 130mg (you will have to waste 20mg from
the 150mg syringe) once every 12 hours Disp #*14 Syringe
Refills:*0
4. Warfarin 6 mg PO DAILY16
RX *warfarin 2 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
5. Simethicone 120 mg PO QID:PRN stomach
6. DiCYCLOmine 20 mg PO TID:PRN stomach pain
7. Sertraline 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Outpatient Lab Work
diagnosis: acute pulmonary embolism, on anticoagulation
date: ___
labs: ___
Send report to ___., Phone: ___, Fax:
___
Discharge Disposition:
Home
Discharge Diagnosis:
acute pulmonary embolism
hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with shortness of breath. Question pneumonia.
COMPARISON: None.
FINDINGS:
Frontal and lateral views of the chest. The lungs are clear of consolidation
or effusion. Cardiac silhouette is enlarged. Hypertrophic changes are noted
in the spine. No acute osseous abnormality detected.
IMPRESSION:
Enlarged cardiac silhouette without definite superimposed acute
cardiopulmonary process.
Radiology Report
HISTORY: Right upper quadrant pain.
COMPARISON: None available.
FINDINGS:
The liver appears diffusely increased in echogenicity consistent with fatty
deposition within the liver. Otherwise, no focal lesions identified within
the liver. There is no intra or extrahepatic ductal dilatation with the
common bile duct measurinh 5 mm. The main portal vein is patent with
hepatopetal flow. The gallbladder contains stone but is without evidence of
distention, gallbladder wall edema, or pericholecystic fluid. Sonographic
___ sign was absent. The pancreas is not well visualized due to
overlying bowel gas. The visualized outline of the aorta appears normal in
caliber.
IMPRESSION:
1. The liver is diffusely increased echogenicity consistent with fatty
deposition within the liver. More significant hepatic disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on the basis of this
study.
2. Cholelithiasis without cholecystitis.
Radiology Report
CHEST CTA PERFORMED ON ___.
COMPARISON: Chest radiograph from same day.
CLINICAL HISTORY: Short of breath, hypoxic, elevated D-dimer, question PE.
TECHNIQUE: Multidetector CT through the chest was performed following IV
contrast administration with multiplanar reformations provided.
FINDINGS: There are multiple filling defects within these lobar and segmental
branches of the bilateral pulmonary arterial tree. There is no saddle embolus
seen and the filling defects are only seen within the lobar branches and
beyond. There is mild flattening of the intraventricular septum, which could
indicate mild right heart strain. The heart is otherwise unremarkable. There
is no lymphadenopathy. The thoracic aorta is normal. The airway is centrally
patent. There is prominent epicardial fat deposition.
Lung windows demonstrate no worrisome nodule, mass, or consolidation. Mild
centrilobular apically predominant emphysema is noted. There is no evidence
of infarction within the lungs. There is no pleural or pericardial effusion.
In the imaged portion of the upper abdomen, fatty liver is noted. There is
likely a gallstone within the gallbladder. The adrenal glands are normal.
BONES: Unremarkable.
IMPRESSION:
1. Bilateral lower lobar and segmental pulmonary emboli with equivocal CT
evidence for right heart strain.
2. No signs of pulmonary infarction.
3. Fatty liver with cholelithiasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SHORTNESS OF BREATH
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 97.9
heartrate: 98.0
resprate: 20.0
o2sat: 91.0
sbp: 129.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ with HTN, obesity presents with DOE and found to have acute
pulmonary embolism. She was admitted to the MICU where she had a
TTE with right heart stain but no failure. She was started on a
heparin drip which was switched to lovenox and warfarin at the
time of discharge.
# Acute pulmonary embolism: She is obese with a sedentary
lifestyle. She does not appear to have other risk factors. She
was treated with heparin drip which was switched to lovenox. She
will start warfarin and follow up with her PCP and
___ clinic for further titration. Her INR goal is
___ and she should be treated for at least 6 months. At the time
of discharge she was able to ambulate on room air without oxygen
desaturation. Her dyspnea was not fully resolved but improved on
discharge.
# Hypokalemia: She was treated with potassium supplementation.
# Anxiety:
- continue home sertraline 50mg daily
- continue home alprazolam 1mg tid prn anxiety
# GERD:
- continue home omeprazole 20mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine / opiates
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a complicated past medical history of longstanding type
2 diabetes on insulin, hypertension, and laryngeal stenosis with
vocal cord paralysis with hx of sudden apneas requiring ongoing
tracheostomy now presents with fevers, generalized weakness, and
malaise. He has a 10-month history of having intermittent
episodes of symptoms including the above along with HA, stiff
neck, shivering cold, and nausea. At the onset of these
symptoms, he generally also has a putrid smell and taste in his
mouth. Due to this and prior purulence from his trach, he has
been intermittently treated with courses of levofloxacin for
presumed tracheitis which always resolve his symptoms and makes
him feel completely well, though the symptoms always recur.
Initially they would recur after a few months, but the period of
time inbetween episodes has progressively shortened. He finished
his most recent levofloxacin course a few weeks ago and started
to feel ill again after a few days.
Over the past ___ days, he has had significant low-grade fevers
99.8-101 associated with similar symptoms including generalized
weakness, malaise, HA, stiff neck, nausea, and also left eye
discomfort with lacrimation. He also has had subjective
confusion recently as well. He saw his ENT doctor today who
preformed a tracheoscopy which did not reveal evidence of
tracheitis. He was therefore sent to the ED for further
evaluation.
On further review of systems, he reports mild burning at the end
of urination, chronic loose stools without any recent change
(non-bloody, non-melenic), and + left eye pressure with
subjective blurriness. Outside of this, he denies any
unintentional weight loss, cough, sputum production, SOB, chest
discomfort, sore throat, abdominal discomfort, vomiting, change
in loose stools, hematuria, penile discharge, flank pain, recent
arthralgias or arthritis, skin rash, oral/genital ulcerations,
or any other complaints.
Of note, he has been worked up extensively by GI for
intermittent diarrhea which has included negative stool studies,
bacterial overgrowth breath testing, colonoscopy, and upper
endoscopy with biopsies (negative for celiac and Whipple's). It
was recommended that he increase his Creon and try immodium for
relief. His symptoms were attributed to possible diabetic
enteropathic diarrhea given the negative work-up.
Finally, he says in the past even prior to these recent 10
months he has had intermittent similar symptoms to a less severe
degree. The possibility of Reactive Arthritis was apparently
raised, though he has not had any treatment for this.
In the ED initial vitals were: 98.0 70 133/88 16 99% RA
- Labs were significant for normal CBC, normal chem 7 save for
creatinine of 1.6 (recent baseline 1.5), negative u/a, and
lactate of 2.6.
- Patient was given 1L NS. He received acetaminophen and no
other medications.
Vitals prior to transfer were: 98.3 72 172/88 16 100% RA
On the floor, initial VS: 98.0 167/94 63 18 98%RA
He was lying comfortably in bed in NAD.
Past Medical History:
Past Medical History:
1. Type 2 diabetes (seen by Dr. ___ at ___.
2. Hypertension.
3. Obstructive sleep apnea.
4. Obesity.
5. Bilateral vocal cord paralysis.
6. Laryngeal stenosis.
7. Nephrolithiasis.
8. Sialolithasis.
9. Chronic sinus and ear infections.
Past Surgical History:
1. Vocal cord implant in ___.
2. C7-T1 spinal fusion in ___, with a repeat fusion in ___.
3. Separated sternum, status post surgical repair in ___.
4. Cholecystectomy in ___.
5. Right shoulder rotator cuff repair ___.
6. Appendectomy.
Social History:
___
Family History:
Does not know his parents, as he is adopted. He has no known
siblings. He has one daughter who is healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.0 167/94 63 18 98%RA
GENERAL: well-developed, well-appearing, obese, adult male lying
comfortably in bed in NAD
HEENT: AT/NC, EOMI without discomfort with eye movement. PERRL.
no scleral injection or icterus. pink conjunctiva, MMM without
ulcerations. good dentition, nontender supple neck, no LAD, no
JVD
CARDIAC: normal rate, regular rhythm. nl 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. no ___ lesions or ___ nodes, no splinter
hemorrhages.
DISCHARGE PHYSICAL EXAM:
VS 98.4/98, 149/76, 71, 16, 100% on RA
GENERAL: well-developed, well-appearing, obese, adult male lying
comfortably in bed in NAD
HEENT: AT/NC, EOMI without discomfort with eye movement. PERRL.
no scleral injection or icterus. pink conjunctiva, MMM without
ulcerations. good dentition, nontender supple neck, no LAD, no
JVD
CARDIAC: normal rate, regular rhythm. nl S1/S2, no murmurs,
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, obese, NTND, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, negative Jolt sign, negative ___
and ___ signs
SKIN: warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
ADMISSION LABS
====================================
___ 01:40PM GLUCOSE-80 UREA N-16 CREAT-1.6* SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 01:40PM WBC-9.2 RBC-4.98 HGB-17.1 HCT-47.4 MCV-95
MCH-34.3* MCHC-36.0* RDW-12.4
___ 01:40PM NEUTS-66.2 ___ MONOS-6.6 EOS-5.8*
BASOS-0.9
___ 01:40PM ALBUMIN-4.4 CALCIUM-9.7 PHOSPHATE-2.3*
MAGNESIUM-1.9
___ 01:40PM ALT(SGPT)-26 AST(SGOT)-22 LD(LDH)-208 ALK
PHOS-98 TOT BILI-0.4
___ 01:40PM LIPASE-59
___ 04:56PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 05:04PM LACTATE-2.6*
DISCHARGE LABS
=====================================
___ 01:45AM BLOOD ESR-4
___ 01:45AM BLOOD CRP-3.7
___ 01:45AM BLOOD HIV Ab-PND
STUDIES
=====================================
___ CXR
FINDINGS: The patient is status post sternotomy.
Discontinuities of sternal wires appear unchanged. There is an
apparently closed tracheostomy with a stent and overlying clips,
but correlation with current status and any history of
instrumentation is recommended. The cardiac, mediastinal and
hilar contours appear unchanged including mild cardiomegaly.
The lungs appear clear. There are no pleural effusions or
pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary disease.
MICROBIOLOGY
=====================================
___
Blood cultures x 2 pending
___ 1:45 am SEROLOGY/BLOOD Source: Venipuncture.
RAPID PLASMA REAGIN TEST (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO BID
2. GlipiZIDE 10 mg PO BID
3. Creon 12 2 CAP PO TID W/MEALS
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal once
daily
8. Vitamin D 1000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Magnesium Oxide 400 mg PO DAILY
12. Cyanocobalamin 100 mcg PO DAILY
13. Glargine 15 Units Breakfast
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 6 Units Dinner
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Creon 12 2 CAP PO TID W/MEALS
3. Furosemide 20 mg PO BID
4. Glargine 15 Units Breakfast
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 6 Units Dinner
5. Lisinopril 10 mg PO DAILY
6. LOPERamide 2 mg PO QID:PRN diarrhea
7. Omeprazole 20 mg PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
9. GlipiZIDE 10 mg PO BID
10. Magnesium Oxide 400 mg PO DAILY
11. Metoprolol Tartrate 25 mg PO DAILY
12. testosterone 1.62 % (20.25 mg/1.25 gram) transdermal once
daily
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever
Secondary:
vocal cord paralysis status-post tracheotomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Shortness of breath.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post sternotomy. Discontinuities of sternal
wires appear unchanged. There is an apparently closed tracheostomy with a
stent and overlying clips, but correlation with current status and any history
of instrumentation is recommended. The cardiac, mediastinal and hilar
contours appear unchanged including mild cardiomegaly. The lungs appear
clear. There are no pleural effusions or pneumothorax.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED, HEADACHE
temperature: 98.0
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 133.0
dbp: 88.0
level of pain: 3
level of acuity: 3.0 | ___ with history of IDDM, HTN, obesity, and vocal cord paralysis
with tracheostomy admitted for work-up of subacute worsening of
fevers and malaise in setting of 10 months of intermittent
episodes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with history of blindness and prostate
cancer presenting with shortness of breath.
He reports ___ days of shortness of breath, worse with exertion
unable to even walk a few steps without shortness of breath),
dizziness, and productive cough. His chest and nose feel
congested and he is unable to breathe out of the left nostril.
Unable to see color of sputum because he is blind. No chest pain
except when coughing. No fever/chills, nausea/vomiting, or
diarrhea. Reports LLQ pain with coughing. He smoked 1 ppd up
until four days ago, when he stopped due to shortness of breath.
He was evaluated at an OSH two days ago and was sent ___ with
pills (unclear if these were an antibiotic) and an inhaler,
which did not seem to help. Sister reports failure to thrive at
___ with progressive weight loss for years. Patient's twin
brother died of pancreatic cancer last year.
In the ED, initial vital signs were:
98.4 120 ___ 90% RA
- ED exam was notable for: Congested cough, lungs relatively
clear (?coarse BS at bases), scattered wheeze, abdomen tender in
LLQ but nondistended/soft, no edema. Smelled of smoke.
- Labs were notable for:
FluAPCR positive.
Lactate 1.2.
Electrolyte panel and CBC unremarkable.
CXR showed no cardiopulmonary acute process.
- The patient was given:
___ 16:06 IH Albuterol 0.083% Neb Soln 1 NEB
___ 16:06 IH Ipratropium Bromide Neb 1 NEB
___ 16:06 IVF 1000 mL NS 1000 mL
___ 19:06 PO Azithromycin 500 mg
___ 19:06 PO PredniSONE 40 mg
___ 22:04 IH Albuterol 0.083% Neb Soln 1 NEB
___ 22:04 IH Ipratropium Bromide Neb 1 NEB
He improved substantially after nebulizers. He was observed in
the ED, and was noted to have persistent hypoxia on room air. He
was admitted to medicine for further management.
Upon arrival to the floor, patient endorses improved dyspnea.
Endorses abdominal discomfort, but no recent diarrhea, no n/v.
REVIEW OF SYSTEMS:
[+] per HPI
Past Medical History:
BLINDNESS
ELEVATED BLOOD PRESSURE
H/O PROSTATE CANCER S/P ___ RADICAL PROSTATECTOMY
H/O GASTROESOPHAGEAL REFLUX
Social History:
___
Family History:
Significant for hypertension in his mother's side. Twin brother
died last year of pancreatic cancer.
Physical Exam:
====================
EXAM ON ADMISSION
====================
Vital Signs: 97.4 111/51 94 18 100% RA
General: Alert & oriented x 3; 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, II/VI systolic
murmur, rubs
Lungs: Bibasilar crackles, no wheezing, rhonchi
Abdomen: +bowel sounds, ecchymoses throughout, soft, tenderness
to palpation diffusely, more so on left lower quadrant.
+voluntary guarding. Tenderness over left flank, indurated,
erythematous, drain with 200cc of sanguinous pus.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis. 1+ edema
bilaterally Left > Right
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, gait deferred, +Asterixis.
====================
EXAM ON DISCHARGE
====================
Vital Signs: 99.3, 107, 110/63, 16, 99%RA
General: Thin gentleman, Alert, oriented, no acute distress,
more interactive than previous
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: thin, soft, nontender
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
========================
LABS ON ADMISSION
========================
___ 03:40PM BLOOD WBC-4.5 RBC-4.62 Hgb-14.3 Hct-44.8 MCV-97
MCH-31.0 MCHC-31.9* RDW-13.3 RDWSD-48.0* Plt ___
___ 03:40PM BLOOD Neuts-64.8 Lymphs-18.2* Monos-16.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-2.89 AbsLymp-0.81*
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.01
___ 03:40PM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-138
K-4.9 Cl-97 HCO3-28 AnGap-18
___ 03:40PM BLOOD Calcium-10.2 Phos-4.1 Mg-2.2
___ 03:45PM BLOOD Lactate-1.2
========================
LABS ON DISCHARGE
========================
___ 09:00AM BLOOD WBC-7.2 RBC-4.34* Hgb-13.6* Hct-41.8
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.3 RDWSD-50.5* Plt ___
___ 09:00AM BLOOD Glucose-130* UreaN-20 Creat-0.6 Na-139
K-3.7 Cl-98 HCO3-33* AnGap-12
___ 09:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
========================
MICROBIOLOGY
========================
___ Blood culture - no growth to date
___ Urine culture - no growth
========================
IMAGING/STUDIES
========================
___ CXR - Lungs are hyperinflated without focal consolidation.
Cardiac, mediastinal and
hilar contours are normal. Pulmonary vasculature is not
engorged. No acute
osseous abnormalities seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Nicotine Patch 21 mg TD DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Disposition:
Extended ___
Facility:
___
Discharge Diagnosis:
Primary: Flu, COPD exacerbation
Secondary: weight loss, failure to thrive
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
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Lungs are hyperinflated without focal consolidation. Cardiac, mediastinal and
hilar contours are normal. Pulmonary vasculature is not engorged. No acute
osseous abnormalities seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 98.4
heartrate: 120.0
resprate: 22.0
o2sat: 90.0
sbp: 107.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with history of blindness and prostate
cancer presenting with shortness of breath and positive flu PCR.
# Acute Influenza, COPD:
The patient presented with dyspnea and cough, and was found to
have a positive influenza PCR. A CXR showed no focal
consolidation, but was hyperinflated. Given the patient's 50
pack year smoking history and productive cough with wheeze on
exam, there was concern that the patient had additionally
triggered a COPD exacerbation, though he had no known diagnosis
of COPD. He was treated with oseltamivir for a 5 day course for
influenza. In addition, he was treated with a prednisone burst
and nebulizers. He was weaned to room air. However, as he
continued to desat and become acutely short of breath with
exertion, he was discharged to acute rehab to further recover.
He will likely benefit for further evaluation of COPD in the
outpatient setting.
# Failure to thrive/weight loss:
A review of the patient's chart and a discussion with his sister
showed that he has had significant weight loss. In ___ he
weighed around 150lb, in ___ 132lb, and during this
hospitalization 110lb (BMI 16.7). He has a history of prostate
cancer, s/p radical resection, but was noted to have PSA of 1.3
in ___. A colonoscopy in ___ was normal. There is
concern for lung malignancy given long smoking history. Could
also be related to living situation, as patient lives alone and
is reportedly not consistently able to eat full meals. While
working with ___ he was found to be very deconditioned, and was
discharged to rehab. Further workup was deferred to the
outpatient setting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMH of HTN, DM, HLD, AS s/p AVR
(___), smoldering myeloma, past ETOH abuse presenting with
abdominal pain.
He was initially taken to ___ by EMS after he developed
abdominal pain several days ago. He had imaging done showing
diverticulitis and was discharged on ___ on cipro/flagyl. He
presented to the ED on ___ because of persistent abdominal pain.
He reports that initially the pain seemed to get slightly better
after discharge, but then it returned and became progressively
worse. His pain is in the lower abdomen bilaterally and is band
like without radiation. He denies any nausea or vomiting. He has
eaten very little due to the pain, although food does not
particularly worsen his symptoms. He has not had any diarrhea or
fevers at home. Last BM was day of presentation.
His last and only other episode of diverticulitis was ___
years ago.
He does report that he has developed constipation over the past
5 months. His stools appear slightly thinner than previously. He
has not noticed any blood. He also feels that he is not eating
well due to lack of appetite which has persisted for ~2 months.
He also notes that he lost around 10 pounds (213 to 203) in 3
weeks-1 month. He thinks this weight loss is unintentional.
In the ED, initial vitals were: 98 102 113/90 18 98% RA.
Labs notable for WBC 8.7, H/H 11.9/35.9, Plt 256, no bands or
left shift, Cr 1.2 (at baseline), BUN 13, lactate 2.7.
Imaging notable for uncomplicated sigmoid diverticulitis, and a
7mm new pulmonary nodule in LLL.
He was given 2mg IV morphine X 2, Iv cipro/flagyl, and 1L IV NS.
Decision was made to admit for IV antibiotics given "failure" of
outpatient treatment.
On the floor, initial vitals were 97.6 122/74 72 18 97% RA. He
reported that his pain had improved with morphine in the ED.
Past Medical History:
- Severe aortic stenosis ___ cath: valve area 0.7 cm2,
mean gradient 42 L/min)
- Hypertension
- Hyperlipidemia
- Type 2 diabetes mellitus, on oral meds (A1c 6.7 in ___
- Depression
- Gout
- MGUS
- Transaminitis and ?___ (CT abdomen from ___ shows hypodense
liver, consistent with fatty liver)
Social History:
___
Family History:
Father had CAD, CABG for angina. Father and brother have
diabetes. Mother and brother both have hypertension. Mother
with colon cancer. Mother and daughter with breast cancer.
Daughter diagnosed with breast cancer at age ___, had a small
mass removed.
Physical Exam:
ON ADMISSION
============
Vital Signs: 97.6 122/74 72 18 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, tenderness to palpation in lower
abdomen R > L with mild voluntary guarding but rebound or
rigidity
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact, moving all extremities equally
ON DISCHARGE
==============
Vital Signs: 98.1 123/68 78 18 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, obese, tenderness to palpation in lower abdomen R
> L with mild voluntary guarding but no rebound or rigidity
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact, moving all extremities equally
Pertinent Results:
LABS ON ADMISSION
=================
___ 01:45PM BLOOD WBC-8.7 RBC-3.98* Hgb-11.9* Hct-35.9*
MCV-90 MCH-29.9 MCHC-33.1 RDW-12.1 RDWSD-39.3 Plt ___
___ 01:45PM BLOOD Neuts-62.7 ___ Monos-9.6 Eos-2.5
Baso-0.3 Im ___ AbsNeut-5.43 AbsLymp-2.11 AbsMono-0.83*
AbsEos-0.22 AbsBaso-0.03
___ 01:45PM BLOOD Glucose-157* UreaN-13 Creat-1.2 Na-142
K-4.8 Cl-105 HCO3-23 AnGap-19
___ 01:45PM BLOOD ALT-31 AST-40 AlkPhos-50 TotBili-0.3
___ 01:45PM BLOOD cTropnT-<0.01
___ 01:45PM BLOOD Albumin-4.3
___ 01:53PM BLOOD Lactate-2.7*
LABS ON DISCHARGE
==================
___ 04:45AM BLOOD WBC-8.1 RBC-3.73* Hgb-11.3* Hct-34.1*
MCV-91 MCH-30.3 MCHC-33.1 RDW-12.3 RDWSD-40.7 Plt ___
___ 04:45AM BLOOD Glucose-133* UreaN-13 Creat-1.2 Na-136
K-3.9 Cl-100 HCO3-22 AnGap-18
___ 04:45AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.1*
___ 11:57PM BLOOD Lactate-1.2
IMAGING
=======
CT abd/pelvis
IMPRESSION:
1. Uncomplicated sigmoid diverticulitis.
2. Since the CT abdomen and pelvis of ___, there has
been interval
development of a 7 mm pulmonary nodule in the left lower lobe.
RECOMMENDATION(S): 3 month follow-up chest CT of the 7 mm left
lower lobe
pulmonary nodule is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 81 mg PO DAILY
6. GlipiZIDE 5 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth q12hr Disp
#*15 Tablet Refills:*0
7. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp
#*15 Tablet Refills:*0
8. amLODIPine 5 mg PO DAILY
9. GlipiZIDE 5 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Uncomplicated diverticulitis
SECONDARY DIAGNOSIS
=====================
Pulmonary nodule
Diabetes Mellitus Type II
Coronary Artery Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with recently diagnosed diverticulitis on ___ who
presents with worsening lower abdominal pain. Bilateral lower quadrant
tenderness to palpation on exam. Evaluate for bowel perforation or worsening
diverticulitis.
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) = 963 mGy-cm.
COMPARISON: CT abdomen pelvis of ___.
FINDINGS:
LOWER CHEST: A 7 mm nodule in the left lower lobe (2:2) is new since ___. No pericardial or pleural effusions. Dense aortic valve calcifications
are present.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of symmetric size with normal nephrogram. There is
no hydronephrosis. Two subcentimeter hypodensities in the right kidney are
too small to characterize by CT, but statistically likely cysts. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is sigmoid
diverticulosis, with an area of asymmetrically increased adjacent fat
stranding, wall thickening, and hyperemia in the mid lower abdomen (2:70,
602b:45), compatible with known diverticulitis. No free intraperitoneal air
or drainable fluid collection detected. The appendix is normal.
PELVIS: Mild thickening of the bladder wall is likely reactive in the setting
of adjacent diverticulitis (602b:45). The distal ureters are unremarkable.
There is no free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease involving the abdominal aorta and the origin of the its great vessels
and extending into the common iliac arteries is again noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Uncomplicated sigmoid diverticulitis.
2. Since the CT abdomen and pelvis of ___, there has been interval
development of a 7 mm pulmonary nodule in the left lower lobe.
RECOMMENDATION(S): 3 month follow-up chest CT of the 7 mm left lower lobe
pulmonary nodule is recommended.
NOTIFICATION: The above findings and recommendation were communicated via
telephone by Dr. ___ to Dr. ___ at 17:00 on ___, 10 min after
discovery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Depression
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding
temperature: 98.0
heartrate: 102.0
resprate: 18.0
o2sat: 98.0
sbp: 113.0
dbp: 90.0
level of pain: 10
level of acuity: 2.0 | ___ with PMH of HTN, DM, HLD, AS s/p AVR (___), smoldering
myeloma, ETOH abuse presenting with abdominal pain due to
diverticulitis.
# Diverticulitis: Originally diagnosed at ___ and was discharged
there on ___. Presented to ___ bc of ongoing pain. On repeat
imaging on this admission, remains uncomplicated. Most likely
not a failure of PO antibiotics from ___ since symptoms may take
some time to resolve. He has fortunately not developed
complicated disease. Last colonoscopy in ___, recommend repeat
in ___ due to only fair prep. Continued on cipro/flagyl while
in house. He was able to tolerate food at discharge. Would
recommend follow up colonoscopy after acute diverticulitis
resolves to exclude underlying malignancy, particularly given
weight loss and change in stool pattern.
# Elevated lactate: likely dehydration, and after fluids,
resolved.
# Pulmonary nodule: new 7mm pulmonary nodule. Reimaging
recommended at ___ months. Colonoscopy as above.
# History of alcohol abuse: reports no alcohol in the past ___
years.
Continued thiamine, multivitamin, folate
# DM: Held home metformin and glipizide. ISS continued while
hospitalized
# CAD s/p CABG: Continued home aspirin and atorvastatin
# Hypertension: Held home amlodipine 5mg in the setting of
initial poor PO intake.
TRANSITIONAL ISSUES
===================
[]Should finish cipro and flagyl course- take up to and
including ___.
[]3 month follow-up chest CT of the 7 mm left lower lobe
pulmonary nodule is recommended. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / hydrochlorothiazide / metformin
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
___ 06:45AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.3* Hct-34.4
MCV-90 MCH-27.0 MCHC-29.9* RDW-16.0* RDWSD-52.9* Plt ___
___ 04:25PM BLOOD Neuts-83.3* Lymphs-11.6* Monos-3.8*
Eos-0.5* Baso-0.4 Im ___ AbsNeut-11.22* AbsLymp-1.57
AbsMono-0.51 AbsEos-0.07 AbsBaso-0.06
___ 04:25PM BLOOD ___ PTT-29.0 ___
___ 04:25PM BLOOD Glucose-349* UreaN-10 Creat-0.9 Na-139
K-4.6 Cl-99 HCO3-23 AnGap-17
___ 04:25PM BLOOD ALT-13 AST-11 AlkPhos-105 TotBili-0.6
___ 04:25PM BLOOD Albumin-3.8 Calcium-7.8* Phos-2.9 Mg-1.3*
Cholest-194
___ 04:25PM BLOOD %HbA1c-11.3* eAG-278*
___ 04:25PM BLOOD Triglyc-132 HDL-63 CHOL/HD-3.1
LDLcalc-105
___ 07:07AM BLOOD TSH-1.8
___ 07:07AM BLOOD Free T4-1.4
___ 05:05PM BLOOD ___ pO2-49* pCO2-42 pH-7.41
calTCO2-28 Base XS-1
___ 05:05PM BLOOD O2 Sat-81
DISCHARGE LABS
___ 06:45AM BLOOD WBC-7.8 RBC-3.81* Hgb-10.3* Hct-34.4
MCV-90 MCH-27.0 MCHC-29.9* RDW-16.0* RDWSD-52.9* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-127* UreaN-14 Creat-1.0 Na-140
K-4.2 Cl-101 HCO3-26 AnGap-13
___ 06:45AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
IMAGING
CXR ___
IMPRESSION:
Hilar adenopathy compatible with patient's history of
sarcoidosis as seen
previously though likely worse compared to ___. Increased
interstitial
markings in the lungs. Underlying parenchymal changes in the
setting of
sarcoidosis would be possible though atypical infection or
component of edema
are also possible.
LOWER EXTREMITY ULTRASOUND FOR DVT ___
IMPRESSION:
Technically limited due to body habitus however no evidence of
deep venous
thrombosis in the right or left lower extremity veins.
TRANSTHORACIC ECHO ___
IMPRESSION: Suboptimal image quality. Moderate pulmonary
hypertension. Hyperdynamic left ventricle. Compared with the
prior TTE (images not available for review) of ___ ,
pulmonary artery pressure is now measurable Moderate pulmonary
hypertension with evidence of right ventricular pressure
overload is now present. EF 76%.
CTA ___
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Diffuse ground-glass opacities associated interlobular septal
thickening
suggestive of mild pulmonary edema.
Redemonstration of enlarged mediastinal and hilar lymph nodes
consistent with history of sarcoidosis.
DISCHARGE PHYSICAL EXAM
VS: 98.3 PO 122 / 78 86 18 98 Ra
GENERAL: Alert and interactive. In no acute distress. Obese,
seated in chair on oxygen.
EYES: NCAT. Conjugate gaze. Sclera anicteric and without
injection.
ENT: MMM. JVP difficult to assess given habitus, appears to be
mid neck
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: CTAB, no crackles.
ABDOMEN: Normal bowel sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No clubbing, cyanosis. Sock indentations bilaterally with
1+
ankle edema, adioposity around calves, tender b/l. Warm
PSYCH: appropriate, good mood and affect
Radiology Report
INDICATION: ___ with dyspnea // dyspnea. History of sarcoidosis.
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___. Chest CTs from ___ and ___.
FINDINGS:
Bilateral hilar adenopathy is most likely due to adenopathy in light of
patient's history of sarcoidosis. The degree of hilar enlargement appears
slightly worse compared to exam from ___. Increased interstitial markings in
the lungs bilaterally. No confluent consolidation. No pleural effusion.
IMPRESSION:
Hilar adenopathy compatible with patient's history of sarcoidosis as seen
previously though likely worse compared to ___. Increased interstitial
markings in the lungs. Underlying parenchymal changes in the setting of
sarcoidosis would be possible though atypical infection or component of edema
are also possible.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: Ms. ___ is a ___ with history of pulmonary hypertension,
sarcoidosis c/b L optic perineuritis, obesity, COPD, HTN, DMII, presenting for
dyspnea. // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Note is made the exam is technically limited due to body habitus however there
is normal compressibility, color flow, and spectral doppler of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow 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:
Technically limited due to body habitus however no evidence of deep venous
thrombosis in the right or left lower extremity veins.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: Ms. ___ is a ___ with history of pulmonary hypertension,
sarcoidosis c/b L optic perineuritis, obesity, COPD, HTN, DMII, presenting for
dyspnea. // r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 37.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 575.4
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP =
11.6 mGy-cm.
Total DLP (Body) = 589 mGy-cm.
COMPARISON: Multiple prior chest CTs, most recently from ___.
FINDINGS:
HEART AND VASCULATURE:
No filling defect in the main pulmonary artery throughout its subsegmental
branches bilaterally. The pulmonary artery is slightly enlarged measuring 3.4
cm in
The heart is normal in size and shape. No pericardial effusion. Mild
atherosclerotic calcifications are noted in the LAD, none in the coronary
arteries and aorta. The aorta is normal in caliber throughout.
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is heterogeneous, unchanged from prior. No enlarged lymph nodes
in either axilla or thoracic inlet. No abnormalities on the chest wall. No
atherosclerotic calcifications in the head and neck arteries.
MEDIASTINUM AND HILA:
The esophagus is unremarkable. Several mediastinum and hilum lymph nodes are
again noted to be enlarged, unchanged in size from prior study, the largest in
the subcarinal station measuring 1.8 cm in short axis diameter (301:80 6%.
PLEURA:
No pleural effusions. Mild bilateral apical scarring.
LUNGS:
Respiratory motion artifacts impair optimal parenchymal evaluation. The
airways are patent to the subsegmental levels. Mild diffuse bronchial wall
thickening, no bronchiectasis or mucus plugging. Several simple cysts are
seen scattered throughout the parenchyma, unchanged from prior study, the
largest in the anterior aspect of the left upper lobe measuring up to 3.4 cm
(301:71). Mild centrilobular pulmonary emphysema is again noted. Mild
diffuse ground-glass opacities are noted in both lungs associated with mild
interlobular septal thickening. No suspicious lung nodules or masses.
CHEST CAGE:
No acute fractures. Mild dorsal spondylosis. No suspicious lytic or sclerotic
lesions.
UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant abnormal
findings.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Diffuse ground-glass opacities associated interlobular septal thickening
suggestive of mild pulmonary edema.
Redemonstration of enlarged mediastinal and hilar lymph nodes consistent with
history of sarcoidosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hyperglycemia
Diagnosed with Dyspnea, unspecified
temperature: 98.5
heartrate: 91.0
resprate: 22.0
o2sat: 95.0
sbp: 144.0
dbp: 91.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE:
=====================
Ms. ___ is a ___ with history of pulmonary hypertension,
sarcoidosis c/b L optic perineuritis, obesity, hypertension,
type 2 diabetes mellitus, who recently finished high dose
prednisone taper, presenting with progressive with dyspnea as
well as hyperglycemia. She was started on a Lasix drip with
boluses of IV Lasix. However, patient with variable weight and
continued lower extremity edema which made establishing her dry
weight difficult. Though Ms. ___ felt her dyspnea had
improved from presentation, she continued to require oxygen
above her baseline needs. It was felt that further diuresis in
the hospital would not significantly improve her breathing or
decreased her oxygen needs at this time. She desired discharge.
On day of discharge she desaturated to 67% when ambulating on
stairs without oxygen and 71% briefly when ambulating up stairs
with oxygen. Discussed with patient that she would need to wear
oxygen at all time to maintain oxygen saturation above 85%. She
agreed and understood the risks of not wearing oxygen and having
significant desaturations. Her home torsemide was increased to
80mg torsemide daily. During her hospitalization our pulmonary
team assessed her and thought that her dyspnea was due to
increased volume status and will follow up with her as an
outpatient. Additionally, the ___ diabetes team was
extensively involved in assisting with medication management
given patient's diabetes was not well controlled with A1c of
11.3% on admission and her difficulty affording medications. She
was provided with 14-day free supply of NPH/humalog upon
discharge and urged to call her insurance to change plans for
the upcoming year. She was provided with 30-day free supply of
lancets/test strips/syringes upon discharge. She was scheduled
for follow-up with pulmonary, her primary care physician, and
___ prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lipitor / Lisinopril / Bactrim DS
Attending: ___.
Chief Complaint:
facial swelling
Major Surgical or Invasive Procedure:
I+D of sub-mandibular, parapharyngeal and sub-masseteric abscess
from odontogenic infection by ___ on ___
History of Present Illness:
Ms. ___ is a ___ female with a past medical history
of hypertension who presents with facial edema. Patient recently
underwent a tooth extraction. Post procedurally the doctor
placed her on a 5-day course of clindamycin. Patient reports
after discontinuation of antibiotics she began to have worsening
facial edema, pain, difficulty swallowing. She presented to her
dentist office today who advised her to come to the emergency
department. She denies fevers, chills, breathing.
___ the ED, she was febrile with a temperature of 101.5 T-max.
She was given IV morphine for pain normal saline, Tylenol
clindamycin and Dilaudid. Laboratories significant for WBC 14.5
and NA 129
CT scan of the face shows a 0.6 x 2.8 cm right subperiosteal
abscess with extension into the medial pterygoid muscle and
masseter muscle compatible with odontogenic abscess with
leftward deviation of the pharynx and pharyngeal fat. She was
seen by OMFS and taken to the OR. Patient was seen
post-operatively. She reported continued pain ___ the right face
however improved.
Past Medical History:
Bariatric surgery
Social History:
___
Family History:
notable for Colon cancer, coronary artery disease
Physical Exam:
ADMISSION:
==========
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and ___ no apparent distress
FACE: R face with significant submandibular edema extending
medially, ___ drains ___ place
EYES: Anicteric, pupils equally round
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally ___ all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
.
.
DISCHARGE EXAM:
================
VS: 24 HR Data (last updated ___ @ 1155) Temp: 98.3 (Tm
98.8), BP: 161/95 (146-171/74-95), HR: 76 (60-76), RR: 16
(___), O2 sat: 96% (94-96), O2 delivery: RA
GEN: Alert and ___ no apparent distress sitting up ___ bed
FACE: R face with significant submandibular edema extending
medially but this is improving, ___ drains have been
removed, trachea is midline. Trismus improving.
EYES: Anicteric, pupils equally round
CV: RR, no m/r/g
RESP: Lungs clear to auscultation with good air movement b/l
GI: soft, not tender to palpation, BS+
SKIN: no jaundice
NEURO: awake, alert, conversant with clear speech, facial
asymmetry from swelling rather than any apparent CN motor
deficits
PSYCH: pleasant, appropriate affect
.
.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
========================
___ 12:04PM BLOOD WBC-14.5* RBC-4.71 Hgb-12.6 Hct-37.5
MCV-80* MCH-26.8 MCHC-33.6 RDW-14.9 RDWSD-42.8 Plt ___
___ 12:04PM BLOOD Glucose-125* UreaN-14 Creat-0.9 Na-129*
K-5.1 Cl-86* HCO___-27 AnGap-16
MICRO:
======
___ Blood Cx: NGTD
___ Blood Cx: NGTD
___ 10:57 pm SWAB RIGHT SUBMANDIBULAR SPACE ABSCESS.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
MODERATE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY
TYPES)
CONSISTENT WITH OROPHARYNGEAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
IMAGING/OTHER STUDIES:
===================
CT sinus/mandible/maxilla ___
"FINDINGS: Socket from prior right mandibular molar extraction
is seen. Adjacent increased sclerosis of the right mandible is
suggestive of chronic inflammation. Along the lingular aspect
and under body of the right half of the mandible, there is a
multiloculated complex rim enhancing fluid collection with
lobulated extension into the medial pterygoid muscle and
inferior aspect of the masseter. The subperiosteal portion of
the abscess measures 0.6 x 2.8 cm (transverse x AP; series 3,
image 107; series 602, image 46). Multiple lobulations are seen
with the largest component measuring 1.2 x 1.8 cm (series 3,
image 90) ___ the medial pterygoid. Reactive inflammatory
changes including surrounding fat stranding and thickening of
the right platysma muscle. Subsequently, there is also leftward
shift of the oropharynx and parapharyngeal fat. No facial bone
or mandibular fracture. Pterygoid plates are intact. The
temporomandibular joints are anatomically aligned. The orbits
are intact. Incidental note of bilateral optic nerve head
drusens. Otherwise, the globes and extraocular muscles are
unremarkable. No orbital hematoma.
Included paranasal sinuses are clear. Included extracranial
soft tissues are unremarkable.
IMPRESSION: A 0.6 x 2.8 cm right subperiosteal abscess with
extension into the medial pterygoid muscle and masseter muscle,
compatible with an odontogenic abscess. Subsequently, there is
leftward deviation of the pharynx and parapharyngeal fat. "
___ Panorex
"FINDINGS: Lucent area ___ the right mandible situated between
___ 18 and 21 correlates with the CT finding of bone destruction
and abscess. Multiple dental fillings. Remaining teeth appear
otherwise unremarkable.
IMPRESSION: Lytic area ___ the right mandible corresponding to
recent CT Findings."
LABS ON DISCHARGE:
================
___
WBC-7.2
RBC-4.37
Hgb-11.7
Hct-35.5
MCV-81*
MCH-26.8
MCHC-33.0
RDW-14.7
RDWSD-43.8
Plt ___
DIFF: Neuts-64.3 ___ Monos-7.5 Eos-3.1 Baso-0.4 Im
___ AbsNeut-4.63 AbsLymp-1.76 AbsMono-0.54 AbsEos-0.22
AbsBaso-0.03
Glucose-100
UreaN-8
Creat-0.5
Na-138
K-3.8
Cl-98
HCO3-26
AnGap-14
Albumin-3.4*
Calcium-9.0
Phos-3.3
Mg-1.9
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID Duration: 7 Days
Do not exceed 4000 mg of acetaminophen from all sources ___ any
24-hour period.
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 7 Days
RX *chlorhexidine gluconate [Peridex] 0.12 % Rinse mouth with 15
mL twice a day Refills:*0
3. LevoFLOXacin 500 mg PO Q24H
last dose will be on ___
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
last dose will be on ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
taper and stop over next ___ days
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h:PRN Disp #*20 Tablet
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY Duration: 7 Days
Titrate for goal 1 bowel movement per day.
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 dose by mouth
Daily, as directed Disp #*14 Packet Refills:*1
7. Atenolol 100 mg PO DAILY
RX *atenolol 100 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
8. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*7 Tablet Refills:*0
9. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daiily Disp #*7 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Sepsis
# Mandibular/pterygoid/masseter abscess
# Essential HTN
# Hx of gastric bypass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST
INDICATION: ___ with recent right lower molar extraction p/w face swelling
and trismus// eval for abscess over the right mandible
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 25.9 mGy (Head) DLP = 581.3
mGy-cm.
Total DLP (Head) = 581 mGy-cm.
COMPARISON: None.
FINDINGS:
Socket from prior right mandibular molar extraction is seen. Adjacent
increased sclerosis of the right mandible is suggestive of chronic
inflammation. Along the lingular aspect and under body of the right half of
the mandible, there is a multiloculated complex rim enhancing fluid collection
with lobulated extension into the medial pterygoid muscle and inferior aspect
of the masseter. The subperiosteal portion of the abscess measures 0.6 x 2.8
cm (transverse x AP; series 3, image 107; series 602, image 46). Multiple
lobulations are seen with the largest component measuring 1.2 x 1.8 cm (series
3, image 90) in the medial pterygoid. Reactive inflammatory changes including
surrounding fat stranding and thickening of the right platysma muscle.
Subsequently, there is also leftward shift of the oropharynx and
parapharyngeal fat.
No facial bone or mandibular fracture. Pterygoid plates are intact. The
temporomandibular joints are anatomically aligned. The orbits are intact.
Incidental note of bilateral optic nerve head drusens. Otherwise, the globes
and extraocular muscles are unremarkable. No orbital hematoma.
Included paranasal sinuses are clear. Included extracranial soft tissues are
unremarkable.
IMPRESSION:
A 0.6 x 2.8 cm right subperiosteal abscess with extension into the medial
pterygoid muscle and masseter muscle, compatible with an odontogenic abscess.
Subsequently, there is leftward deviation of the pharynx and parapharyngeal
fat.
Radiology Report
EXAMINATION: Panorex radiograph.
INDICATION: Odontogenic infection.
COMPARISON: CT is available from the same day.
FINDINGS:
Lucent area in the right mandible situated between ___ 18 and 21 correlates
with the CT finding of bone destruction and abscess. Multiple dental
fillings. Remaining teeth appear otherwise unremarkable.
IMPRESSION:
Lytic area in the right mandible corresponding to recent CT Findings.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Facial swelling
Diagnosed with Localized swelling, mass and lump, head, Essential (primary) hypertension
temperature: 98.2
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 161.0
dbp: 63.0
level of pain: 8
level of acuity: 3.0 | ___ w/ HTN, hx of gastric bypass, admitted for urgent I+D of
sub-mandibular, parapharyngeal and Sub-masseteric Abscess from
odontogenic infection.
.
. |
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:
Percutaneous cholecystostomy tube ___
History of Present Illness:
HPI: ___ with 6 days of RUQ pain, which started after eating,
and
has been fairly constant since that time. The pain became
acutely worse this morning, and she was seen by her PCP who
recommended she present to the ED. She has had some subjective
chills, as well as some diarrhea for the past 5 days. She
states
she had similar, transient pain when she was younger, which she
attributed to ulcers, but has not had pain in many years. She
has not noted any association with eating, and has not had any
nausea or vomiting. She has been able to eat small meals and
drink water without nausea or exacerbation of pain
Past Medical History:
PMH: GERD, ulcer disease, hypertension
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission ___
Temp: 99.7 HR: 79 BP: 124/69 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Comfortable; well-appearing
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, +RUQ TTP, + ___ sign
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petec
Pertinent Results:
___ 04:55AM BLOOD WBC-12.9* RBC-3.50* Hgb-10.8* Hct-32.1*
MCV-92 MCH-30.9 MCHC-33.7 RDW-11.8 Plt ___
___ 04:55AM BLOOD WBC-15.8* RBC-3.56* Hgb-11.0* Hct-32.8*
MCV-92 MCH-30.8 MCHC-33.5 RDW-11.6 Plt ___
___ 04:40AM BLOOD WBC-12.0* RBC-3.70* Hgb-11.7* Hct-34.3*
MCV-93 MCH-31.7 MCHC-34.2 RDW-11.6 Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD ___ PTT-30.5 ___
___ 04:55AM BLOOD Glucose-100 UreaN-11 Creat-0.8 Na-134
K-3.5 Cl-98 HCO3-30 AnGap-10
___ 04:55AM BLOOD Glucose-87 UreaN-12 Creat-0.5 Na-136
K-3.8 Cl-99 HCO3-28 AnGap-13
___ 04:55AM BLOOD ALT-53* AST-95* AlkPhos-206* Amylase-29
TotBili-0.7
___ 04:55AM BLOOD ALT-44* AST-37 AlkPhos-154* TotBili-0.5
___ 06:42PM BLOOD ALT-104* AST-140* AlkPhos-201*
TotBili-0.5
___ 04:55AM BLOOD Lipase-16
___ 06:42PM BLOOD Lipase-31
___ 10:49PM BLOOD Lactate-1.1
___: EKG:
Sinus rhythm. Prolonged P-R interval. No previous tracing
available for
comparison
___: US liver/gallbladder:
IMPRESSION: Severe gallbladder wall thickening, with apparent
anterior focal wall irregularity which could be artifactual, but
discontinuity of the wall is not excluded. No large fluid
collections or biliary dilation. CT may be helpful for further
evaluation.
___: US of gallbladder:
IMPRESSION: Findings consistent with acute cholecystitis,
probably with a
focal perforation interposed between the gallbladder and liver.
Mild luminal distention is noted, and percutaneous
cholecystostomy tube placement is scheduled to be attempted.
___: ___: GB drainage:
IMPRESSION: Technically successful ultrasound-guided
percutaneous
cholecystostomy tube placement. Technically difficult study
requiring two
passes. 40 mL of purulent appearing fluid was drained. Sample
sent for
microbiological analysis. There were no immediate complications.
___ 10:40 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days
SENSITIVITIES
PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0610.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 1:35 pm BILE
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary
Medications on Admission:
___: omeprazole 40", tylenol 3 prn, prilosec 20', atenolol
12.5', lisinopril 10', prozac 20', simvastatin ___ every other
day, asa 81', calcium +D, multivitamin, folate
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain: may cause increased drowsiness, avoid
driving while on this medicaiton.
Disp:*30 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with cholelithiasis, right upper quadrant and
epigastric pain x several days.
No prior examinations for comparison.
RIGHT UPPER QUADRANT ULTRASOUND: The gallbladder is partially distended, with
internal layering stones and sludge. There is severe circumferential wall
edema up to 14 mm, with heterogeneous appearance and increased vascularity.
In the region of the gallbladder fundus, there is questionable focal wall
interruption (images ___ and 46). However, there are no surrounding large
fluid collections.
The liver is normal in echotexture. There is normal hepatopetal flow in the
portal vein. IVC is also patent. There is no intrahepatic or common biliary
ductal dilation, with the latter measuring 3 mm. The pancreas is obscured by
overlying bowel gas. There is no pancreatic duct dilation. The right kidney
measures 12.4 cm, without stones, masses, or hydronephrosis.
IMPRESSION: Severe gallbladder wall thickening, with apparent anterior focal
wall irregularity which could be artifactual, but discontinuity of the wall is
not excluded. No large fluid collections or biliary dilation. CT may be
helpful for further evaluation.
Radiology Report
CLINICAL INFORMATION: ___ female with right upper quadrant pain, for
preoperative evaluation.
COMPARISON: None.
FINDINGS: Frontal and lateral chest radiographs demonstrate clear lungs
without effusion or pneumothorax. Note is made of an azygos fissure. The
heart size is normal, and the mediastinal contours are unremarkable.
IMPRESSION: Clear lungs without acute chest pathology.
Radiology Report
INDICATION: Acute cholecystitis for seven days and previous ultrasound
showing gallbladder wall thickening. Please evaluate size of the gallbladder
lumen to check if amenable to percutaneous cholecystostomy tube placement.
COMPARISON: ___.
TECHNIQUE: Right upper quadrant ultrasound.
FINDINGS: Previous ultrasound of ___ had showed findings
consistent with acute cholecystitis, but the gallbladder lumen was largely
collapsed without sufficient distention to permit attempt of cholecystostomy
tube placement. Repeat examination was performed to reassess gallbladder
lumen size.
Hepatic echotexture appears within normal limits. Common hepatic duct
measures 6 mm. Gallbladder is markedly abnormal, with extensive mural edema
and a focal fluid collection interposed between the gallbladder and liver that
measures approximately 2.2 x 1.4 cm, an appearance which is suggestive of a
perforated cholecystitis with a small subhepatic/pericholecystic collection.
The lumen is still not markedly distended; however, in comparison with the
examination of ___, the degree of distention has increased slightly.
It is felt that percutaneous cholecystostomy tube placement could be
attempted, though it is expected to be difficult. Imaged portion of pancreas
appear within normal limits with portions of the pancreatic head and tail
obscured by overlying bowel gas.
IMPRESSION: Findings consistent with acute cholecystitis, probably with a
focal perforation interposed between the gallbladder and liver. Mild luminal
distention is noted, and percutaneous cholecystostomy tube placement is
scheduled to be attempted.
Radiology Report
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY DATED ___
INDICATION: ___ with acute cholecystitis for six days. Please place
percutaneous cholecystostomy tube.
COMPARISON: Comparison is made to previous ultrasound dated ___
and ___.
PHYSICIANS: Dr. ___ and Dr. ___ performed the
procedure. Dr. ___ attending radiologist, was present throughout the
procedure.
PROCEDURE: Following a detailed discussion of the risks, benefits, and
alternatives to the procedure, written informed consent was obtained. The
patient was transferred to the ultrasound suite and placed in the supine
position. An initial preprocedure ultrasound was performed for purposes of
skin point localization prior to cholecystostomy tube placement. This again
demonstrated a markedly abnormal gallbladder with massive wall thickening and
edema and a small collection located between the gallbladder and liver edge
consistent with prior perforation. Preprocedure timeout was performed as per
___ protocol using two unique patient identifiers.
The skin overlying the right upper quadrant was prepped and draped in usual
sterile fashion. Approximately 8 mL of 1% lidocaine was infiltrated into the
skin, subcutaneous tissue, and into the liver capsule under ultrasound
guidance. An 8 ___ pigtail catheter was inserted into the liver and
gallbladder under ultrasound guidance. The procedure was technically
difficult due to marked induration in the region of the severely inflamed
gallbladder, and required two passes for placement of the 8 ___ pigtail
catheter. Once satisfactorily position was confirmed within the gallbladder,
the pigtail tube was advanced over the trocar and pigtail was formed within
the gallbladder. 40 mL of yellow and red-tinged purulent fluid was aspirated.
A sample was sent for a microbiological analysis as requested. The catheter
was attached to a closed drainage system on free drainage.
There were no immediate complications. The patient tolerated the procedure
well.
SEDATION: Moderate sedation was provided by administering divided doses of
fentanyl 100 mcg and Versed 2 mg throughout the total intraservice time of 35
minutes, during which the patient's hemodynamic parameters were continuously
monitored.
The patient was transferred back to the floor in stable condition. POE orders
were entered on the online system.
IMPRESSION: Technically successful ultrasound-guided percutaneous
cholecystostomy tube placement. Technically difficult study requiring two
passes. 40 mL of purulent appearing fluid was drained. Sample sent for
microbiological analysis. There were no immediate complications.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ
temperature: 99.7
heartrate: 79.0
resprate: 16.0
o2sat: 98.0
sbp: 124.0
dbp: 69.0
level of pain: 4
level of acuity: 3.0 | ___ year old female admitted to the acute care sevice with right
upper quadrant abdominal pain. Upon admission, she was made
NPO, given intravenous fluids, and underwent ultrasound imaging
of her abdomen. She was reported to have severe gallbladder
wall thickening, with apparent anterior focal wall irregularity.
Her blood culture from 1 bottle grew gm + cocci and she was
started on vancomycin and unasyn. Because of the severe
inflammation if the gallbladder, she went to ___ on HD #4 for
placement of a cholecystostomy tube where 40cc of purulent fluid
was drained. Her bile was cultured for gm - rods. Her
vancomycin and zosyn were discontinued on HD # 7 and she was
placed on augmentin to complete her 2 week course of
antibiotics.
Her vital signs are stable and her abdominal pain has decreased.
She is afebrile and her white blood cell count is 13. She is
tolerating a regular diet and voiding without difficulty.
She is preparing for discharge home with the drain in place and
___ services to provide additional support and instruction. She
has been instructed to maintain a record of the drainage and to
bring it with her on her follow-up visit. She will follow up
with the acute care service in 3 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product
Derivatives / Bactrim / lisinopril
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of AF on warfarin, HTN/HL, prior
caudate CVA, and chronic uvular edema/angioedema, presenting s/p
syncopal episode just hours after discharge today from an
admission for angioedema with fiberoptic intubation. She was at
home, walking with 2 aids when she complained of lightheadedness
and had a brief syncopal episode during which she was helped to
a seated position by the aids, unresponsive ~30 seconds. She
recovered immediately thereafter without any complaints or
evidence of seizure/post-ictal state. She continued to have mild
nausea without vomiting, so was brought back for evaluation.
Upon arrival she was asymptomatic.
During her previous admission, no precipitating triggers of her
angioedema were identified. She only required a few hours of
intubation for airway protection and was continued on an oral
regimen of antihistamines and a prednisone taper with resolution
of her symptoms. Per her transitional issues, she will followed
up with Allergy as an outpatient with Dr. ___. She was also
symptomatic with evidence of a UTI on urine culture, discharged
with ciprofloxacin to finish today. Family requested a skin
biopsy during her admission, which is currently pending. She was
also deemed a fall risk, per her evaluation by ___ while in
house.
In the ED, initial VS were: 97.2 75 161/79 16 95% RA. EKG showed
AF at 60bpm, RBBB, QTc 486 (previously 466) with inf/lat ST
changes. Labs were notable for creatinine of 1.2, increasing
from 1.0 earlier in the day in the ED. CXR showed "worsening
CHF" and a right-sided pleural effusion. She also intermittently
became bradycardic to the ___, but remained asymptomatic,
oxygenating well. Therefore, the decision was made to admit her
to medicine for diuresis and arrhythmia monitoring.
On arrival to the floor, VS 97.9 142/69 60 18 96% RA. Pt does
not recall her syncopal event and denies chest pain,
palpitations, mouth swelling, shortness of breath, cough,
fevers, chills, lightheadedness.
REVIEW OF SYSTEMS:
(-) per HPI and for headache, vision changes, abdominal pain,
nausea, vomiting, diarrhea
Past Medical History:
- Left Caudate Head infarct
- Angioedema: pruritis and periorbital and lip/tongue edema,
previously intubated in MICU (___), etiology thought to be due
to lisinospril, which was subsequenlty discontinued. Recurrence
in ___ requiring MICU admission, managed with IV steroids and
H1/H2 blockers, no intubation required.
- Atrial fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Osteoarthritis
- S/p right hip replacement
- Eczema
- ___ as a child
Social History:
___
Family History:
- Cousin with peanut allergy developed in his ___.
- No family history of asthma or eczema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.9 142/69 60 18 96% RA.
GENERAL - elderly female sleeping in bed, easily arousable to
voice, appears comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, breath sounds diminished at bases, no
r/rh/wh, good air movement, resp unlabored, no accessory muscle
use
HEART - PMI non-displaced, irregularly irregular, no MRG, nl
S1-S2
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
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, alert and oriented to person, place and year, CNs
II-XII grossly intact, muscle strength ___ throughout, DTRs 2+
and symmetric, gait deferred
Pertinent Results:
___ 10:45PM GLUCOSE-183* UREA N-43* CREAT-1.2* SODIUM-138
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-30 ANION GAP-16
___ 10:45PM cTropnT-<0.01
___ 10:45PM WBC-10.4 RBC-4.22 HGB-13.3 HCT-40.8 MCV-97
MCH-31.5 MCHC-32.6 RDW-12.7
___ 10:45PM NEUTS-86.0* LYMPHS-6.9* MONOS-6.7 EOS-0.3
BASOS-0
___ 10:45PM PLT COUNT-219
___ 10:45PM ___ PTT-27.4 ___
___ 01:00PM ___ PTT-35.4 ___
___ 06:35AM GLUCOSE-109* UREA N-30* CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
___ 06:35AM WBC-9.5 RBC-3.97* HGB-12.5 HCT-37.9 MCV-96
MCH-31.5 MCHC-32.9 RDW-12.4
___ 06:35AM PLT COUNT-201
___ 06:15AM GLUCOSE-109* UREA N-30* CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
___ 06:15AM CALCIUM-9.3 PHOSPHATE-2.0* MAGNESIUM-1.8
___ 06:15AM WBC-10.3 RBC-3.93* HGB-12.4 HCT-38.3 MCV-97
MCH-31.6 MCHC-32.4 RDW-12.8
___ 06:15AM PLT COUNT-190
TTE ___:
The left atrium is dilated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is
borderline/mild bileaflet mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Tricuspid valve prolapse is present. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
EKG ___:
Atrial fibrillation. Right axis deviation. Right bundle-branch
block.
Non-specific ST-T wave changes. Compared to tracing #2 no
diagnostic interval change. QT/QTc: 470/478
CXR ___:
Previous pleural effusions have substantially decreased. Lungs
are clear. Moderate cardiomegaly stable. Normal pulmonary
vasculature.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. PredniSONE 20 mg PO DAILY Duration: 1 Days
___
Tapered dose - DOWN
5. PredniSONE 10 mg PO DAILY Duration: 2 Days
___
6. PredniSONE 5 mg PO DAILY
starting ___
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Fexofenadine 60 mg PO BID
9. Acetaminophen 1000 mg PO Q8H
10. Alendronate Sodium 70 mg PO QWEEK
11. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -200 unit Oral BID
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 1 mg PO QPM
15. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Fexofenadine 60 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
3. PredniSONE 5 mg PO DAILY
starting ___
4. Simvastatin 20 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 1 mg PO QPM
7. Amlodipine 5 mg PO DAILY
8. Docusate Sodium 200 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 2 TAB PO HS
11. Acetaminophen 1000 mg PO Q8H
12. Alendronate Sodium 70 mg PO QWEEK
13. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -200 unit Oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Syncope
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: Syncope.
COMPARISON: Chest radiograph from ___ and CT torso from ___.
CHEST, AP AND LATERAL: Increased mild pulmonary edema with central venous
congestion, , moderate right and small left pleural effusions. Moderate
cardiomegaly is chronic. Compression deformities of a mid thoracic vertebra,
with near complete loss of height; and lower thoracic vertebra, with 50% loss
of anterior height, unchanged for at least five months. Mild left
acromioclavicular arthropathy.
IMPRESSION: Increasing congestive heart failure.
Radiology Report
AP CHEST, ___, 9:17 A.M.
HISTORY: ___ woman with atrial fibrillation, pleural effusions and
now a white count, question pneumonia.
IMPRESSION: AP chest compared to ___:
Previous pleural effusions have substantially decreased. Lungs are clear.
Moderate cardiomegaly stable. Normal pulmonary vasculature.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SYNCOPE/PRESYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, PULMONARY CONGESTION & HYPOSTASIS, ATRIAL FIBRILLATION, CARDIAC DYSRHYTHMIAS NEC, HYPERTENSION NOS
temperature: 97.2
heartrate: 75.0
resprate: 16.0
o2sat: 95.0
sbp: 161.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ F with history of atrial fibrillation on warfarin,
hypertension, and chronic idiopathic uvular edema/angioedema
discharged ___ after treatment of angioedema and readmitted
the same day for witnessed pre-syncopal/syncopal episode at
assisted living.
# Syncope/Pre-syncope: Per report, pt was lightheaded and was
helped to a seated position by aids, unclear if there was true
loss of consciousness. Of note, patient was "hyper and giddy"
prior to the episode per report of home aid, raising suspicion
for medication side effect given recent addition of 2
antihistamines and high dose predisone for angioedema.
Differential also included vasovagal, neurologic and cardiac
etiologies. Lack of focal neuro deficits and normal neuro exam
made CVA/TIA unlikely, seizure also unlikely given lack of
post-ictal period. ACS unlikely given lack of acute change on
EKG and negative cardiac enzymes x 2. Valvular dysfunction
considered given R>L pleural effusions on CXR. TTE ___
showed Moderate (2+) mitral regurgitation, no aortic stenosis
or other valvular dysfunction. Bradycardia on telemetry as
described below. Pt denied dizziness, lightheadedness this
admission and had no further syncopal episodes.
# Bradycardia: Per ED report, pt initially had bradycardia to
___, asymptomatic. Currently, pt having frequent episodes of
asymptomatic bradycardia in ___ with ___ second pauses. Beta
blocker held. Suspect that current antihistamine regimen for
recent angioedema contributing. Spoke with pt's allergist Dr.
___ believes that steroids are a more important
component of her angioedema treatment than the antihistamines at
this point and noted that pt was on fairly low doses of both
famotidine and fexofenadine. Cardiology evaluated patient and
recommended decreased dose of metoprolol, no indication for
pacemaker.
# ___: Resolved. Creatinine 1.2 from 1.0 at discharge. Likely
pre-renal etiology given response to fluids.
# Leukocytosis: WBC 12.2 ___. Pt was afebrile with no
localizing infectious symptoms. UA negative, chest x-ray showed
improvement in pleural effusions and no focal infiltrate.
Recheck was 11.2 on day of discharge.
# Chronic angioedema: Pt recently admitted for angioedema which
required brief intubation for airway protection. Was discharged
on day of presentation with no symptoms of angioedema with plan
to continue prednisone taper and follow up with her allergist.
Prednisone taper was continued and patient discharged on 5mg
daily with plan to continue at that dose until seen for
scheduled follow up in allergy clinic. Due to concern that
antihistamines may have been contributing to her
dizziness/syncope prior to admission as well as her bradycardia
on telemetry, famotidine was held and fexofenadine continued. Pt
denied any symptoms of angioedema this admission.
# Hypertension: Home beta blocker was discontinued due to
bradycardia as described above. Subsequently, SBP elevated
160s-170s, patient asymptomatic. Home HCTZ continued and low
dose amlodipine added with better control of blood pressure.
# Atrial fibrillation: Pt was kept on home warfarin dose 1 mg
daily
# Hyperlipidemia: continued simvastatin
# Osteoporosis: continued calcium and vitamin D |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ibuprofen / Keflex / Antihistamines / Latex / Bactrim
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with PMHx of UC (s/p colectomy), DVT (on coumadin)
who presents after fall and questionable LOC. Patient was in her
kitchen this morning and rose from a chair to get a cup of
coffee. She reports "blacking out" without any warning and
falling to the ground. She does not think she passed out, and
she did not hit her head. She called her daughter who came to
her aid. There was no chest pain, shortness of breath,
palpitations, lightheadedness.No prior episodes of syncope or
seizure. No urinary incontinence. She was noted by EMS to have a
large laceration on the dorsal surface of her left hand as well
as skin tears on her left shoulder and right elbow.
In the ED, initial VS were 98.4 90 183/106 20 98%RA. Initial
labs were significant for no leukocytosis, H/H 12.3/39.4, INR
3.9. Chem panel significant for Na 149, K 4.9, Cl 114, HCO3 17,
BUN 20, Cr 1.4. AG was 18. Noncontrast CT head was negative for
acute process. EKG reportedly NSR NANI, no ST changes.
She was given 2mg morphine x2 and tetanus vaccine.
Transfer VS were 98.4 103 108/56 19 97% RA.
On arrival to the floor, patient reports no pain, no dizziness.
Denies headache, blurry vision, focal weakness or numbness. She
does report that she has felt weak for the past several weeks
generally, with poor PO intake over several months. Denies
fevers, chills, cough, abdominal pain, dysuria, hematuria.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
- Refractory colitis s/p subtotal colectomy
- Pyoderma gangrenosum
- Breast CA s/p left lumpectomy + XRT
- GERD
- Glaucoma
- HTN
- Hypothyroidism
- Depression
- Osteoporosis
- Basal cell ca
PAST SURGICAL HISTORY:
- s/p ex lap, subtotal colectomy and ileostomy
- s/p left salpingo-ophrectomy,
- s/p multiple parastomal hernia repairs, including one with
ileal resection
- s/p left breast biopsy
- SBO
- History of DVT, on warfarin
- CKD
- Pseudogout
- Blepharitis (OD)
Social History:
___
Family History:
-Father with MI, stroke
-Mother with MI
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
========================================
VS: 98.1 116/60 96 26 99%RA
BP lying 118/74
BP standing 72/48
General: Awake, alert, oriented x3. Lying in bed, with left hand
in skyhook.
HEENT: Right pupil larger than left, right also barely reactive.
Right lower eyelid with ectropion. Sclera nonicteric. Somewhat
dry mucous membranes, no oral lesions.
Neck: Supple. No cervical or supraclavicular LAD.
CV: Tachycardic, regular rhythm. No murmur appreciated.
Lungs: Lungs clear with some decreased air movement at the
bases.
Abdomen: BS+. Soft, nondistended. Mild diffuse tenderness.
Ostomy on left side, with brown semi-formed stool.
GU: Deferred. No foley.
Ext: 1+ ___ edema. Hyperpigmentation of the LEs, consistent with
chronic venous stasis.
Neuro: AOx3. CN2-12 grossly intact. Strength not tested, though
moving all four extremities with no focal deficits.
Skin: Very thin, fragile, dry. 12cm skin tear over the dorsum of
the left wrist. 24x24cm skin tear over left shoulder.
PHYSICAL EXAM ON DISCHARGE:
========================================
VS: 97.5 124/61 73 16 96%RA
BP lying 130/64
BP sitting 120/60
General: Awake, alert, oriented x3. Sitting up in bed, eating
breakfast.
HEENT: Right pupil larger than left, right also barely reactive.
Right lower eyelid with ectropion. Sclera nonicteric. MMM, no
oral lesions.
Neck: Supple. No cervical or supraclavicular LAD.
CV: RRR. No murmur appreciated.
Lungs: Lungs clear with some decreased air movement at the
bases.
Abdomen: BS+. Soft, nondistended, nontedner. Ostomy on left
side, with brown semi-formed stool and some liquid.
GU: Deferred. No foley.
Ext: Trace ___ edema. Hyperpigmentation of the LEs, consistent
with chronic venous stasis.
Neuro: AOx3. CN2-12 grossly intact. Strength not tested, though
moving all four extremities with no focal deficits.
Skin: Very thin, fragile, dry. 12cm skin tear over the dorsum of
the left wrist, is also about 1cm wide. 24x24cm superficial skin
tear over left shoulder.
Pertinent Results:
LABS:
=====================================
___ 08:30AM BLOOD WBC-6.9 RBC-4.05* Hgb-12.3 Hct-39.4
MCV-97 MCH-30.3 MCHC-31.1 RDW-13.7 Plt ___
___ 08:30AM BLOOD Neuts-63.9 ___ Monos-8.3 Eos-3.3
Baso-0.8
___ 08:30AM BLOOD ___ PTT-46.0* ___
___ 08:30AM BLOOD Glucose-122* UreaN-20 Creat-1.4* Na-149*
K-4.9 Cl-114* HCO3-17* AnGap-23*
___ 08:30AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8
___ 08:42AM BLOOD Lactate-1.5
___ 05:40AM BLOOD WBC-6.7 RBC-3.07* Hgb-9.2* Hct-28.5*
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.1 Plt ___
___ 05:40AM BLOOD Glucose-82 UreaN-13 Creat-1.1 Na-144
K-3.7 Cl-109* HCO3-25 AnGap-14
___ 05:40AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.6
___ 05:40AM BLOOD ___ PTT-28.7 ___
___ 05:40AM BLOOD WBC-7.3 RBC-3.06* Hgb-9.2* Hct-28.2*
MCV-92 MCH-30.2 MCHC-32.7 RDW-14.0 Plt ___
___ 05:40AM BLOOD ___ PTT-31.8 ___
___ 05:40AM BLOOD Glucose-92 UreaN-14 Creat-1.3* Na-144
K-4.6 Cl-111* HCO3-27 AnGap-11
REPORTS:
=====================================
-GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFTStudy Date of
___:
IMPRESSION:
No left shoulder acute fracture or dislocation.
-HAND (AP, LAT & OBLIQUE) LEFTStudy Date of ___:
IMPRESSION:
No left hand or wrist fracture or dislocation.
-CHEST (PA & LAT)Study Date of ___:
MPRESSION:
No acute cardiopulmonary process.
-CT HEAD W/O CONTRASTStudy Date of ___:
IMPRESSION: No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. Align (bifidobacterium infantis) 4 mg oral daily
4. Cyanocobalamin 1000 mcg PO DAILY
5. Miconazole 2% Cream 1 Appl TP PRN ostomy change
6. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID
7. Warfarin 2 mg PO 3X/WEEK (___)
8. Warfarin 3 mg PO 4X/WEEK (___)
9. Multivitamins 1 TAB PO DAILY
10. Pataday (olopatadine) 0.2 % ophthalmic 1 drop in both eye
daily
Discharge Medications:
1. Artificial Tears Preserv. Free 2 DROP BOTH EYES BID
2. Cyanocobalamin 1000 mcg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Acetaminophen 1000 mg PO TID
This should be given TID for 7-days and then changed to PRN
basis.
6. Heparin 5000 UNIT SC BID
7. Mirtazapine 7.5 mg PO HS
8. Align (bifidobacterium infantis) 4 mg oral daily
9. Miconazole 2% Cream 1 Appl TP PRN ostomy change
10. Multivitamins 1 TAB PO DAILY
11. Pataday (olopatadine) 0.2 % ophthalmic 1 drop in both eye
daily
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Syncope
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Weakness.
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Frontal and lateral views of the chest. High position of the IVC filter is
similar to prior. Heart size and cardiomediastinal contours are stable.
Aortic knob calcification is unchanged. The lungs are clear without focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Status post fall with left hand pain.
COMPARISON: None.
FINDINGS:
3 views the left hand, 3 views of the left wrist, and dedicated scaphoid view.
Evaluation of fine bony detail is mildly limited by overlying cast material.
Within this limitation, no fracture or dislocation. Joint narrowing with
subchondral sclerosis and marginal osteophytes are noted involving the PIP and
DIP joing as well as the ___ CMC and triscaphe joints. No focal lytic or
sclerotic lesion. Marked soft tissue swelling with subcutaneous gas is seen
overlying the dorsum of the hand and wrist.
IMPRESSION:
No left hand or wrist fracture or dislocation.
Radiology Report
HISTORY: Status post fall with pain in left shoulder and hand.
COMPARISON: None.
FINDINGS:
4 views of the left shoulder. No fracture or dislocation. Acromioclavicular
and coracoclavicular intervals are maintained. Moderate acromioclavicular
degenerative changes. No focal lytic or sclerotic lesion.
IMPRESSION:
No left shoulder acute fracture or dislocation.
Radiology Report
HISTORY: Fall on Coumadin.
COMPARISON: Comparison is made with CTA head from ___.
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 hemorrhage, edema, mass effect, or
infarction. Prominent ventricles and sulci suggest age related involutional
changes or atrophy. Periventricular white matter hypodensities are consistent
with chronic small vessel ischemic disease. The basal cisterns appear patent
and there is preservation of gray-white matter differentiation.
No fracture is identified. Scattered areas of aerosolized secretions are seen
in the ethmoid air cells and sphenoid sinuses, suggestive of mild acute sinus
disease. Otherwise, the visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The globes are intact.
IMPRESSION: No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF WRIST, TETANUS TOXOID INOCULAT, UNSPECIFIED FALL
temperature: 98.4
heartrate: 90.0
resprate: 20.0
o2sat: 98.0
sbp: 183.0
dbp: 106.0
level of pain: 4
level of acuity: 2.0 | PRIMARY REASON FOR HOSPITALIZATION:
=================================================
___ y/o female with PMHx of UC (s/p colectomy), DVT (on coumadin)
who presents after fall at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ketorolac / B blockers / Percocet / Toradol / Dilaudid /
levofloxacin / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___
___ Complaint:
Left sided abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___ note:
"Ms. ___ is a ___ woman with history of DVT/PE
on warfarin, HTN, HLD, thoracic radiculitis, endometriosis,
irritable bowel syndrome, s/p CCY, s/p appendectomy presenting
with abdominal pain.
The patient reports that she was in her usual state of health
until about two months when she developed left sided abdominal
pain. She also reported loose watery stools, as well has
dizziness and lightheadedness. She saw her PCP for this on ___,
and was thought to have gastroenteritis and advised to continue
to adhere to a BRAT diet and continue to drink fluids. She also
started taking a probiotic with enzymes. Labs at that time
notable for a lipase of 155 (ULN 82), LFTs and BMP wnl. Stool
cultures were negative. The patient reports that she tried the
BRAT diet for a few more days but did not notice any difference
in her pain or other symptoms and became discouraged so she
discontinued it.
She reports that her pain worsened over the past several days.
It
is primarily left-sided, upper and lower, and feels "dull like a
toothache". The pains is present continuously, associated with
nausea and dry heaving. She has had little to eat or drink in
the
last two days due to pain and nausea. She continues to have
loose
watery stools, ___ per day, and bloating. She denies any fevers
or chills. She reports that the pain is exacerbated by
everything: sitting, walking, eating. She does not use NSAIDs
and
does not drink alcohol. She reports that she has been on the
same
medications at the same doses for years. No travel or sick
contacts.
She presented again to her PCP today for evaluation. CT obtained
notable for ___ inflammatory change adjacent to the
neck of the pancreas suggestive acute pancreatitis so she was
referred to the ED for further management.
Of additional note, the patient has a history of right-sided
abdominal pain thought to be due to thoracic radiculitis for
which she is followed by pain clinic. She feels that this
current
pain is different from that right-sided pain.
In the ED, vitals: Tmax 100.0, 89, 131/86 20 100% RA
Exam notable for: Abdomen mildly distended, ttp in epigastric
and
LLQ, normal bowel sounds
Labs notable for: WBC 5.9, Hb 9.5, INR 4.6; LFTs wnl, lipase 58;
lactate 1.4
Imaging: CXR
Patient given: morphine 4 mg IV, Zofran 4 mg IV, 2L LR
On arrival to the floor, the patient reports that she continues
to have left-sided abdominal discomfort and nausea. She has dry
heaves but no emesis. She continues to have several watery loose
stools per day.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. "
Past Medical History:
- DVT/PE on warfarin
- HTN
- HLD
- Mitral valve prolapse
- Thoracic radiculitis
- GERD
- Anemia/thalassemia trait
- Asthma
- Endometriosis
- Irritable bowel syndrome
- Generalized anxiety disorder
- PTSD
- Affective psychosis
- S/p CCY
- S/p appendectomy
Social History:
___
Family History:
No known family history of pancreatic or biliary disease.
Physical Exam:
ADMISSION EXAM:
VITALS: 99.3 136/86 70 18 98 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, tender to palpation in left
upper quadrant without rebound or guarding. Bowel sounds present
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
=====================================
DISCHARGE EXAM:
VITALS: ___ Temp: 98.3 PO BP: 125/84 HR: 72 RR: 18 O2
sat: 98% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, mildly distended, mildly tender to palpation
in
LUQ. Bowel sounds present but hypoactive. Obese.
GU: No GU catheter present
MSK: Moves all extremities, no edema or swelling
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented x3, face symmetric, speech fluent, moves
all limbs
PSYCH: Pleasant, flat affect, calm, cooperative
Pertinent Results:
LABS ON ADMISSION:
___ 03:43PM BLOOD WBC-5.9 RBC-4.57 Hgb-9.5* Hct-30.9*
MCV-68* MCH-20.8* MCHC-30.7* RDW-18.5* RDWSD-41.7 Plt ___
___ 03:43PM BLOOD Neuts-64.2 ___ Monos-10.9
Eos-0.9* Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-1.35
AbsMono-0.64 AbsEos-0.05 AbsBaso-0.03
___ 03:43PM BLOOD ___ PTT-40.7* ___
___ 03:43PM BLOOD Glucose-103* UreaN-7 Creat-0.9 Na-139
K-4.1 Cl-106 HCO3-20* AnGap-13
___ 03:43PM BLOOD ALT-22 AST-29 AlkPhos-105 TotBili-0.3
___ 03:43PM BLOOD Lipase-58
___ 03:43PM BLOOD cTropnT-<0.01
___ 03:43PM BLOOD Albumin-3.7 Calcium-8.7 Phos-2.0* Mg-2.0
___ 03:43PM BLOOD Triglyc-84
___ 05:30AM BLOOD tTG-IgA-8
___ 03:48PM BLOOD Lactate-1.4
___ 03:50PM URINE Color-Straw Appear-Clear Sp ___
___ 03:50PM URINE Blood-SM* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:50PM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
=====================
LABS ON DISCHARGE:
___ 05:50AM BLOOD WBC-4.3 RBC-4.70 Hgb-9.5* Hct-31.5*
MCV-67* MCH-20.2* MCHC-30.2* RDW-17.2* RDWSD-40.2 Plt ___
___ 05:50AM BLOOD ___
___ 05:50AM BLOOD Glucose-47* UreaN-7 Creat-0.8 Na-144
K-4.1 Cl-108 HCO3-20* AnGap-16
___ 05:30AM BLOOD ALT-19 AST-18 AlkPhos-99 TotBili-0.4
___ 05:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0
=====================
MICROBIOLOGY:
___ 3:50 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 3:25 pm STOOL CONSISTENCY: WATERY Source:
Stool.
C. difficile PCR (Final ___:
NEGATIVE.
___ 3:25 pm STOOL CONSISTENCY: WATERY Source:
Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Pending):
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___ 12:31 pm STOOL CONSISTENCY: SOFT Source:
Stool.
OVA + PARASITES (Pending):
=====================
CT ABDOMEN/PELVIS ___: (ATRIUS)
IMPRESSION: Peripancreatic inflammatory change adjacent to the
neck of the pancreas, extending towards the porta hepatis,
suggesting acute pancreatitis. Status post cholecystectomy and
appendectomy.
CXR ___:
No acute cardiopulmonary abnormality.
EKG ___:
Normal sinus rhythm. No significant change compared with ___
EKG.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with abdominal pain, vomiting and pancreatitis//
?pulmonary edema, pna
TECHNIQUE: AP and lateral chest radiographs were obtained
COMPARISON: CT dated ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax identified.
There is no evidence of pulmonary edema. The size of the cardiac silhouette
is mildly enlarged but unchanged.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Epigastric pain, Left lower quadrant pain, Essential (primary) hypertension
temperature: 97.2
heartrate: 89.0
resprate: 20.0
o2sat: 100.0
sbp: 131.0
dbp: 86.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ woman with history of DVT/PE on
warfarin, HTN, HLD, thoracic radiculitis, endometriosis,
irritable bowel syndrome, s/p CCY, s/p
appendectomy who presented with left sided abdominal pain (since
___, worsened over several days), nausea and vomiting.
She was still having some moderate LUQ pain and nausea, that
seem to worsen with attempts at eating. She was going to try
solid food for dinner, but said she was nauseated. I discussed
with her that I wanted to make sure she could keep down adequate
liquids and solid food such as dinner tonight and breakfast
tomorrow and if so, that she could likely go home tomorrow. She
was initially in agreement, but then said she really wanted to
go home. She said that she had kept down soda and fluids and
said she thought that she would feel better and do better at
home. I explained that I would prefer that she make sure that
she could eat solid food before going home. She expressed
understanding the risks of going home and said that if her pain
or nausea significantly worsened, she could return to the ED.
She also felt like she could manage her symptoms with the same
PRN medications at home as she is getting here. I discussed
with her that she needs her INR rechecked to determine when to
restart warfarin and to see her PCP within the next 1 week. She
agreed and said she would make sure to do these things. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lithium
Attending: ___
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
EGD and colonoscopy on ___
History of Present Illness:
___ with PMH of bipolar disorder, gastritis, colonic polyps and
GERD with ongoing workup for diarrhea and anemia who presented
after a pre-syncopal episode at her PCP's office while waiting
in
line to drop off a stool sample. She felt lightheaded and fell,
but denies LOC, head strike, CP, SOB, nausea, palpitations.
After
this episode, labs were drawn at her PCP's office which was
concerning for Hgb 7.4. She was sent to ___ ED for further
workup.
She was previously hospitalized at ___ from ___ for
hypotension, nonbloody vomiting and diarrhea. At that time she
had a BP in the 70's with tachycardia in the 120's. She received
a CT abdomen which showed diverticulosis, hepatic steatosis, and
sigmoid colitis. There was an initial concern for pancreatitis
given her elevated lipase, however, there was no evidence on CT
imaging. Her electrolytes were repleted. Stool cultures
including
bacteria, c diff, norovirus were all negative. She was
discharged
on a 7 day course of cipro (refused to take flagyl due to
nausea). She did not receive any scopes at that time.
Since her discharge in ___, her diarrhea and vomiting have not
completely resolved. She has had ongoing outpatient workup for
diarrhea and anemia. Patient states she has felt ongoing
fatigue,
anorexia, as well as weight loss over the past few months
(unintentional).
Denies NSAID use, is not anticoagulated. Patient states she has
___ alcoholic drinks per day, smokes 1 pack cigarettes per day.
Occasional marijuana use, otherwise denies any drug use.
Past Medical History:
Diverticulitis ___
hypertension
bipolar disorder
Social History:
___
Family History:
Father: HTN, diverticulitis (1 episode)
Mother: good health
FH of colon cancer, cholecystitis
Physical Exam:
ADMISSION EXAM:
VS: ___ Temp: 98.0 PO BP: 123/78 R Lying HR: 89 RR: 18
O2 sat: 99% O2 delivery: Ra
Appearance: pale, middle aged woman lying in bed, no acute
distress
Eyes: no conjuctival injection, anicteric
ENT: no sinus tenderness,
Respiratory: good air movement throughout, faint expiratory
wheezing
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: distended, nontender to palpation in all
quadrants, no rebound or guarding
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: alert, able to answer all questions
DISCHARGE EXAM:
T98.6 PO 103 / 68 103 18 98 Ra
Appearance: NAD, alert and oriented x3
Eyes: no conjuctival injection, anicteric
Respiratory: CTAB
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: distended, nontender to palpation in all
quadrants, no rebound or guarding
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: alert, able to answer all questions
Pertinent Results:
ADMISSION LABS:
___ 04:18PM BLOOD WBC-11.7*# RBC-2.18* Hgb-7.0* Hct-21.5*
MCV-99* MCH-32.1*# MCHC-32.6 RDW-22.0* RDWSD-79.3* Plt ___
___ 04:18PM BLOOD Neuts-82.3* Lymphs-9.8* Monos-5.9
Eos-0.6* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-9.62*#
AbsLymp-1.14* AbsMono-0.69 AbsEos-0.07 AbsBaso-0.07
___ 04:18PM BLOOD ___ PTT-28.7 ___
___ 04:18PM BLOOD Glucose-115* UreaN-4* Creat-0.5 Na-140
K-3.4 Cl-96 HCO3-26 AnGap-18
___ 04:18PM BLOOD ALT-6 AST-50* LD(LDH)-306* AlkPhos-171*
TotBili-1.1 DirBili-0.4* IndBili-0.7
___ 07:00AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.2* Iron-152
PERINANT INTERVAL LABS:
___ 07:00AM BLOOD Ret Aut-1.1 Abs Ret-0.03
___ 04:18PM BLOOD ___ 07:00AM BLOOD Lipase-66*
___ 07:00AM BLOOD ALT-<5 AST-33 LD(LDH)-227 AlkPhos-140*
TotBili-1.2
___ 07:00AM BLOOD TSH-5.5*
___ 07:20AM BLOOD T4-8.3
___ 07:00AM BLOOD CRP-8.6*
___ 08:39AM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-8.3 RBC-2.64* Hgb-8.3* Hct-25.0*
MCV-95 MCH-31.4 MCHC-33.2 RDW-20.9* RDWSD-69.4* Plt ___
___ 07:20AM BLOOD Glucose-86 UreaN-<3* Creat-0.4 Na-141
K-3.6 Cl-102 HCO3-24 AnGap-15
IMAGING/REPORTS:
___ RUQS:
LIVER: The liver is diffusely echogenic. The contour of the
liver is smooth. There is no focal liver mass. The main portal
vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.3 cm.
KIDNEYS: The right kidney measures 11.0 cm. She left kidney
measures 11.1 cm. No hydronephrosis or suspicious renal mass.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
Echogenic liver consistent with steatosis. Other forms of liver
disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
EGD ___:
Impression: (biopsy)
Abnormal mucosa in the stomach (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: - Follow up with biopsy results
- Proceed with colonoscopy
Colonoscopy ___:
Impression: Internal hemorrhoids
Diverticulosis of the colon
(biopsy)
Otherwise normal colonoscopy to cecum
Recommendations: - Follow up on biopsy results
- Refer to GI consult team for further recommendations
- Given suboptimal prep and purpose of colonoscopy, procedure
was inadequate for colorectal screening and the patient should
continue her current schedule of screenings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RisperiDONE 1 mg PO QHS
2. Omeprazole 40 mg PO BID
3. Sucralfate 1 gm PO TID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea/loose stool
Hold if No BM, discuss increasing with your PCP if not
sufficient
RX *loperamide 2 mg 1 tab by mouth QIDPRN Disp #*120 Capsule
Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. Omeprazole 40 mg PO BID
6. RisperiDONE 1 mg PO QHS
7. Sucralfate 1 gm PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pre-syncope
Anemia
Secondary:
Etoh use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypotension, tachycardic, pre-syncope, likely
slow GIB, smokes ppd// any evidence of acute cardio/pulm process?
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph on ___
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion.
IMPRESSION:
No acute cardiopulmonary abnormality
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with h/o EtOH abuse, chronic diarrhea, possible
GIB, syncope// Please evaluate hepatic parenchyma and biliary tree for
possible etiology of diarrhea and/or any other acute process in patient with
long history of alcohol use
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 12.3 cm.
KIDNEYS: The right kidney measures 11.0 cm. She left kidney measures 11.1 cm.
No hydronephrosis or suspicious renal mass.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fatigue, Presyncope
Diagnosed with Acute posthemorrhagic anemia
temperature: 98.9
heartrate: 107.0
resprate: 22.0
o2sat: 100.0
sbp: 90.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH bipolar disorder, gastritis, colonic polyps and
GERD with ongoing workup for diarrhea and anemia who presented
after a pre-syncopal episode, admitted for further workup of
possible GI bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Lisinopril / Cefaclor / Baclofen /
doxycycline
Attending: ___.
Chief Complaint:
Chest and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HTN, HLD, T2DM c/b neuropathy and gastroparesis,
chronic pancreatitis, prior DVT no longer on anticoagulation,
and
history of epidural abscess s/p T2-T5 laminectomies presents to
the ED with c/o chest and back pain.
She notes that two days ago she developed pain in her left arm
that radiates down the entire arm, is described as "numb and
heavy." She states that her hand feels "like it is a mitten."
There was no preceding trauma or injuries. She does note that
that she has had similar pain in the past when she had an
epidural abscess. She notes that she then developed shortness of
breath and is now having pain with deep inspiration. She then
developed a sense of back pain radiating through to her chest
which she calls "chest pain." She describes the pain as
"squeezing, tight and heavy." The pain is constant with no clear
exacerbating or alleviating factors. She notes associated
nausea.
She denies any fever, abdominal pain, vomiting, diarrhea, BRBPR,
urinary retention, bladder or bowel incontinence, or saddle
anesthesia. A code cord was called on arrival.
In the ED, vitals were: T97.8 HR 99 BP 157/74 RR 18 O2 99 on RA
Exam: Notable for : Tearful, ___ LUE strength, pain with moving
right leg.
Labs: Notable for WBC 5.3, CRP 3.2, D-Dimer 311, Lactate
2.4->2.9, Trop <0.01 x2
Studies:
-MRI w/o contrast (patient refused contrast):
No definitive epidural abscess, though limited by w/o contrast.
Right dorsal lateral epidural T2 signal extends from T4-T9 is
similar from prior study (___) and ventrally displaces thecal
sac w/o definitive cord compression or cord signal
abnormalities.
Could represent epidural lipomatosis, however unusual
configuration.
Cord compression at C5-C6 level of degenerative spinal cord
narrowing, at T3-T9 due to described epidural abnormality.
-CXR
IMPRESSION:
No acute intrathoracic process.
They were given:
___ 01:24IVMorphine Sulfate 4 mg
___ 01:50IVHYDROmorphone (Dilaudid) .5 mg
___ 02:25IVHYDROmorphone (Dilaudid) .5 mg
___ 02:46IVLORazepam 1 ___
___ 04:25IVHYDROmorphone (Dilaudid) .5 mg
___ 08:18IVHYDROmorphone (Dilaudid) .5 mg
___ 08:57SCInsulin 4 ___
___ 09:27PO/NGGabapentin 900 mg
___ 09:27POFenofibrate 145 mg
___ 09:27PO/NGAspirin 81 ___
___ 09:27POMetFORMIN XR (Glucophage XR) 1000 mg
___ 09:27PO/NGDocusate Sodium 100 mg
___ 09:27PO/NGSenna 8.6 ___
___ 11:29IVHYDROmorphone (Dilaudid) .5 mg
___ 13:20SCInsulin 8 ___
___ 15:33IVHYDROmorphone (Dilaudid) .5 mg
On arrival to the floor, patient is tearful and notes that she
is
having chest tightness, pointing to her epigastrium. She notes
that this all started two days ago. She notes that the pain is
reproducible by pushing down on her upper abdomen. When
discussing her back pain, she tells me that it is worse than
usual, but at baseline has been pretty bad after her surgery.
She
is also having decreased sensation of her left arm and
discomfort
of her right leg and feels as if it is very weak. The numbness
of
her left arm is described as if covered by a blanket. She notes
that her left arm is heavy and she feels that she cannot lift it
as well. She states that these symptoms also started >24 hours
ago and are more noticeable now than they were at onset. She
states that these are the exact symptoms from her epidural
abscess. Currently she says that she feels lousy and somewhat
nauseous, but has not vomited. Endorses constipation.
Past Medical History:
UC
Pancreatitis
Gastritis
DM (retinopathy and neuropathy)
Mechanical fall resulting in lumbar spine trauma w/compression
fractures
PE diagnosed in ___, not on anticoagulation
Appendectomy
Cholecystectomy
Increased triglycerides
Obesity
Depression
Endometrial carcinoma s/p hysterectomy
Social History:
___
Family History:
Father - coronary artery disease, diabetes.
Mother - NFS, gadolinium, renal failure, died related to NFS.
Siblings - none.
Daughter is adopted.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in poe
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: Point tenderness below surgical incision site, with
R-flank
tenderness, and significant tenderness to CVA maneuver.
ABDOMEN: Tender to deep palpation in epigastrium and RUQ. No
guarding. No rebound.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM
========================
VITALS:
24 HR Data (last updated ___ @ 048)
Temp: 98.5 (Tm 98.7), BP: 114/71 (108-148/57-79), HR: 97
(92-103), RR: 16 (___), O2 sat: 97% (95-97), O2 delivery: RA
GENERAL: Lying in bed, NAD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB
ABD: soft, normoactive BS, mild epigastric tenderness, RUQ
tenderness. No rebound or guarding.
BACK: Tenderness in upper and mid thoracic spine
NEURO: AAOx3, strength ___ RUE, 4+/5 LUE, ___ LLE, ___ RLE
Pertinent Results:
ADMISSION LABS
==============
___ 09:37PM BLOOD WBC-5.3 RBC-4.58 Hgb-12.7 Hct-39.0 MCV-85
MCH-27.7 MCHC-32.6 RDW-12.3 RDWSD-37.5 Plt ___
___ 09:37PM BLOOD Neuts-41.9 ___ Monos-8.9 Eos-3.4
Baso-0.9 Im ___ AbsNeut-2.22 AbsLymp-2.33 AbsMono-0.47
AbsEos-0.18 AbsBaso-0.05
___ 09:37PM BLOOD Glucose-392* UreaN-22* Creat-0.7 Na-139
K-4.3 Cl-103 HCO3-22 AnGap-14
___ 09:37PM BLOOD cTropnT-<0.01
___ 06:06AM BLOOD D-Dimer-311
___ 01:10AM BLOOD ALT-24 AST-20 AlkPhos-54 TotBili-0.3
___ 09:37PM BLOOD cTropnT-<0.01
___ 01:10AM BLOOD Lipase-45
___ 01:10AM BLOOD Albumin-4.1
___ 05:02AM BLOOD VitB12-326
___ 01:10AM BLOOD CRP-3.2
___ 01:18AM BLOOD Lactate-2.4*
DISCHARGE LABS
==============
___ 05:47AM BLOOD WBC-3.6* RBC-3.79* Hgb-10.6* Hct-33.1*
MCV-87 MCH-28.0 MCHC-32.0 RDW-12.4 RDWSD-39.5 Plt ___
___ 05:47AM BLOOD Glucose-244* UreaN-19 Creat-0.8 Na-139
K-4.7 Cl-105 HCO3-25 AnGap-9*
___ 06:00AM BLOOD ALT-30 AST-29 AlkPhos-43 TotBili-<0.2
___ 04:00PM BLOOD cTropnT-<0.01
___ 05:47AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
INTERVAL LABS/MICROBIOLOGY/REPORTS
==================================
MR CERVICAL SPINE W/O CONTRAST Study Date of ___
1. Limited evaluation of epidural abscess in the absence of
intravenous
contrast and motion.
2. Postsurgical changes related to patient's known T2 through T5
neck knees and epidural abscess effect aeration.
3. Within limits of study, no definite evidence of patient's
previously noted epidural abscess.
4. Subcentimeter nonspecific cervical lymph nodes as described,
which may be reactive.
5. Grossly stable multilevel cervical, thoracic, and lumbar
spine spondylosis compared to ___ prior full spine MRI evidence
of moderate or severe vertebral canal or neural foraminal
narrowing.
6. Grossly stable probable epidural lipomatosis as described.
7. Grossly stable chronic L3 anterior compression fracture, as
described.
8. Incompletely characterized left renal punctate at least
partially cystic structure, as described.
CTA CHEST Study Date of ___
1. No evidence of acute aortic abnormality.
2. Evaluation for pulmonary emboli limited by extensive
respiratory motion
artifact. Within this limitation, no pulmonary embolism to
segmental levels.
CT HEAD W/O CONTRAST Study Date of ___
1. No acute intracranial abnormality on noncontrast CT head.
Specifically no acute large territory infarct or intracranial
hemorrhage.
2. Mild age advanced global atrophy.
MRI ___
IMPRESSION:
1. Motion limited exam.
2. S/p laminectomies from T2 through T5. No evidence for
recurrent epidural collection in the cervical, thoracic, or
lumbar spine. No evidence for diskitis or osteomyelitis.
3. Unchanged multilevel degenerative disease in the cervical,
thoracic, and lumbar spine, as well as thoracic dorsal epidural
lipomatosis, as detailed above.
4. Splenomegaly is again partially imaged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fenofibrate 160 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. Gabapentin 1800 mg PO QHS
7. basaglar 45 Units Breakfast
basaglar 45 Units Bedtime
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
9. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100
unit/mL subcutaneous per sliding scale
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth every eight (8) hours Disp #*30 Tablet
Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidocaine Pain Relief] 4 % Place 1 Patch once a
day Disp #*30 Patch Refills:*0
3. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
RX *naproxen 250 mg ___ tablet(s) by mouth twice daily as needed
Disp #*30 Tablet Refills:*0
4. Nortriptyline 25 mg PO QHS
RX *nortriptyline 25 mg 1 capsule(s) by mouth every night Disp
#*30 Capsule Refills:*0
5. Gabapentin 1200 mg PO BID
RX *gabapentin 600 mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
6. Glargine 60 Units Breakfast
Glargine 60 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) ___efore breakfast and before bed Disp
#*3 Syringe Refills:*0
7. Aspirin 81 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Fenofibrate 160 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
12. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100
unit/mL subcutaneous per sliding scale
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Acute on chronic back pain
Chronic Pancreatitis
SECONDARY DIAGNOSES
=====================
Type II Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: ___ with h/o type 2 diabetes, chronic pancreatitis, GBS
bacteremia and epidural abscess status post T2 through T5 laminectomy on
___, here with back pain and left arm/ right leg defiicts
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed.
COMPARISON: MRI cervical, thoracic, lumbar spine without contrast dated ___.
___ cervical and thoracic spine x-ray.
___ torso CT.
FINDINGS:
Study is limited due to patient refusal of administration of intravenous
contrast and motion.
CERVICAL:
Vertebral body alignment is preserved.Vertebral body heights are preserved.
There is no definite focal marrow signal abnormality.The visualized portion of
the spinal cord is grossly preserved in signal and caliber.
There is loss of intervertebral disc signal throughout the cervical spine.
Intervertebral disc heights are grossly preserved.
At C4-5 there is disc bulge, facet joint hypertrophy, ligamentum flavum
thickening, with mild vertebral canal and mild bilateral neural foraminal
narrowing.
At C5-6 there is disc bulge, ligamentum flavum thickening, with mild vertebral
canal and no neural foraminal narrowing.
At C6-7 there is disc bulge, ligamentum flavum thickening, with mild vertebral
canal and no neural foraminal narrowing.
Otherwise, there is no definite evidence of moderate or severe vertebral canal
or neural foraminal narrowing of cervical spine.
THORACIC:
Vertebral body alignment is grossly preserved.
Vertebral body heights are preserved. T5 vertebral body probable hemangioma
is noted. With Schmorl's nodes are seen throughout the thoracic spine.
Postsurgical changes related to interval T2 through T5 laminectomies are
noted.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber.
Intervertebral discheightsandsignalare grossly preserved.
There is redemonstration of a dorsal lateral T1 and T2 hyperintense STIR
hypointense epidural collection extending from T5-T9, causing mild spinal
canal narrowing without definite evidence of cord compression, again
suggestive epidural fat. The previously seen collection at the T2-T5 level
is not seen on the current exam.
Otherwise, there is no definite evidence of moderate or severe thoracic spine
or vertebral canal narrowing.
LUMBAR:
There is minimal dextroscoliosis of the lumbar spine. Grossly stable chronic
L3 approximately 15% anterior compression deformities again seen. Schmorl's
nodes are again seen at multiple levels throughout the lumbar spine. L2 and
L5 probable hemangiomas are noted. Probable transitional anatomy with partial
sacralization of L5 is again noted.
At T12-L1 there is disc bulge, epidural fat, facet joint hypertrophy,
vertebral canal and no neural foraminal narrowing.
L1-2 there is disc bulge, epidural fat, ligamentum flavum thickening, with
mild vertebral canal and no neural foraminal narrowing.
At L2-3 there is disc bulge, epidural fat, ligamentum flavum thickening, facet
joint hypertrophy, with mild vertebral canal and no neural foraminal
narrowing.
At L3-4 there is loss, facet joint hypertrophy, ligamentum flavum thickening,
epidural fat, vertebral canal and mild right neural foraminal narrowing.
At L4-5 there is ligamentum flavum thickening, epidural fat, facet joint
hypertrophy, no canal and no neural foraminal narrowing.
At L5-S1 there is disc bulge, facet joint hypertrophy, ligamentum flavum
thickening, with mild vertebral canal and mild bilateral neural foraminal
narrowing.
OTHER:
Within the limits of this noncontrast study there is no paravertebral or
paraspinal mass identified.
Nonspecific approximately 9 mm right level 2A probable lymph node is seen (see
11:7). Additional nonspecific bilateral level 5 subcentimeter lymph nodes are
seen (see 11: ___.
Limited imaging of the abdomen again suggests probable in the left upper
quadrant (see 12:23 on ___ prior MRI and 13:23 on current study and 05:55 on
___ torso CT).
Limited imaging kidneys again suggests left renal probable parapelvic cyst
(see 14:8 on current study and 5:67 on ___ prior torso CT). Additional
punctate left renal approximately 1 mm T2 hyperintense lesion is seen,
incompletely characterized, and may correspond to punctate left renal
hypodensity seen on prior torso CT (see 14:11 on current study and 5:70 on
___ prior torso CT).
Nonspecific probable dependent edema is noted in the dorsal lumbar soft
tissues.
IMPRESSION:
1. Limited evaluation of epidural abscess in the absence of intravenous
contrast and motion.
2. Postsurgical changes related to patient's known T2 through T5 neck knees
and epidural abscess effect aeration.
3. Within limits of study, no definite evidence of patient's previously noted
epidural abscess.
4. Subcentimeter nonspecific cervical lymph nodes as described, which may be
reactive.
5. Grossly stable multilevel cervical, thoracic, and lumbar spine spondylosis
compared to ___ prior full spine MRI evidence of moderate or severe vertebral
canal or neural foraminal narrowing.
6. Grossly stable probable epidural lipomatosis as described.
7. Grossly stable chronic L3 anterior compression fracture, as described.
8. Incompletely characterized left renal punctate at least partially cystic
structure, as described.
NOTIFICATION: Findings discussed with ___, MD by ___, MD via
telephone at 04:03 on ___.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with strange constellation of symptoms: 2 days
of severe chest pain radiating into the back, L arm numbness and R hip flexor
weakness.// Rule out dissection or other cause of chest pain
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 31.7 cm; CTDIvol = 14.8 mGy (Body) DLP = 467.2
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 3.3
mGy-cm.
Total DLP (Body) = 472 mGy-cm.
COMPARISON: Chest CT ___
FINDINGS:
HEART AND VASCULATURE: Exam is moderately limited by extensive respiratory
motion artifact. Within this limitation, no pulmonary embolism to segmental
levels. The thoracic aorta is normal in caliber without evidence of
dissection or intramural hematoma. The heart, pericardium, and great vessels
are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of acute aortic abnormality.
2. Evaluation for pulmonary emboli limited by extensive respiratory motion
artifact. Within this limitation, no pulmonary embolism to segmental levels.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with strange constellation of symptoms: 2 days
of severe chest pain radiating into the back, L arm numbness and R hip flexor
weakness.// Rule out stroke
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territory infarction,hemorrhage,edema, or
mass. There is mild age advanced global atrophy.
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. Chronic fatty replacement of the
parotid glands.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast CT head. Specifically no
acute large territory infarct or intracranial hemorrhage.
2. Mild age advanced global atrophy.
Radiology Report
INDICATION: ___ with h/o T2DM c/b neuropathy and gastroparesis, chronic
pancreatitis, remote cholecystectomy, w RUQ and chest pain getting opioids and
no BM x4days, reports no gas x 3 d.// Eval for obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
A mild-to-moderate amount of stool is seen, predominantly in the right and
transverse colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Cholecystectomy clips overlie the right upper quadrant. There are no
unexplained soft tissue calcifications or radiopaque foreign bodies.
IMPRESSION:
Nonobstructive bowel gas pattern with mild to moderate colonic fecal load.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old woman with right leg weakness and arm numbness.
Evaluate for epidural abscess. Review of the ___ medical record reveals
that the patient history of epidural abscess status post T2-T5 laminectomies
in ___, admitted for back pain, chest pain, left arm numbness, right leg
weakness. The symptoms are reportedly similar to her prior symptoms in the
setting of prior epidural abscess.
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 7 cc Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: Cervical, thoracic, and lumbar spine MRI without contrast from ___.
Cervical, thoracic, and lumbar spine MRI without contrast from ___.
FINDINGS:
Motion artifact slightly limits evaluation.
The localizer sequence again demonstrates 7 cervical, 12 rib-bearing, and 5
lumbar-type vertebrae, as well as a partially lumbarized S1, as seen
previously.
CERVICAL:
No evidence for diskitis, osteomyelitis, epidural collection, or paravertebral
collection. No evidence for pathologic intrathecal contrast enhancement. No
spinal cord signal abnormalities are identified on sagittal T2 weighted
allowing for mild motion artifacts; evaluation on axial T2 weighted images is
much more limited by motion.
The cerebellar tonsils are normally positioned. Visualized posterior fossa
appears unremarkable.
C2-C3: No significant spinal canal narrowing. Mild left neural foraminal
narrowing by facet osteophytes.
C3-C4: No significant spinal canal narrowing. Neural foraminal narrowing by
left uncovertebral and facet osteophytes appears mild on motion limited
evaluation.
C4-C5: No significant spinal canal narrowing. Neural foraminal narrowing by
uncovertebral and facet osteophytes appears at least mild on the right and at
least moderate on the left on motion limited evaluation.
C5-C6: No evidence for significant spinal canal narrowing. Neural foraminal
narrowing by uncovertebral and facet osteophytes appears at least mild
bilaterally on motion limited evaluation.
C6-C7: No evidence for significant spinal canal narrowing. Left neural
foraminal narrowing by uncovertebral and facet osteophytes appears mild on
motion limited evaluation.
C7-T1: No evidence for spinal canal or neural foraminal narrowing.
THORACIC:
S/p laminectomies at T2 through T5. No evidence for recurrent epidural
collection. No thecal sac narrowing at the surgical levels. No evidence for
rim enhancing collection in the overlying soft tissues. No evidence for
pathologic intrathecal contrast enhancement. No evidence for spinal cord
signal abnormalities allowing for motion artifact. No evidence for diskitis
or osteomyelitis. No prevertebral collection. Unchanged vertebral body
heights. Specifically, mild T12 superior endplate deformity with mild loss of
height are again noted. Mild anterior wedging of T6 and T7 vertebral bodies
are also again noted. A small hemangioma is again seen within the T5
vertebral body.
Dorsal epidural lipomatosis is again seen from T5 through T9.
At T5-T6, there is a small right paracentral disc protrusion which minimally
indents the ventral thecal sac. The ventral surface of the cord is mildly
remodeled, but the cord is surrounded by plentiful CSF laterally and
posteriorly. These findings are unchanged compared to ___.
At T7-T8, there is a right paracentral disc herniation covered by endplate
osteophytes, indenting the ventral thecal sac and approaching the right
ventral spinal cord without cord compression. There is overall mild narrowing
of the thecal sac by the osteophytes and dorsal epidural lipomatosis. No
change compared to ___.
At T8-T9, there is a right paracentral disc protrusion covered by endplate
osteophytes, which in combination with dorsal epidural lipomatosis causes mild
narrowing of the thecal sac without mass effect on the spinal cord. No change
since the ___ MRI.
Mild disc bulges facet arthropathy are again seen at T10-T11, T11-T12, and
T12-L1, without significant spinal canal narrowing.
LUMBAR:
Mild L1 vertebral body loss of height, as well as moderate L3 vertebral body
loss of height minimal retropulsion, are unchanged. Multiple hemangiomas are
again seen, largest within the L5 vertebral body. No evidence for diskitis,
osteomyelitis, epidural collection, or paravertebral collection. No
pathologic intrathecal contrast enhancement. The conus medullaris appears
unremarkable, terminating at L1, as seen previously.
L1-L2: Mild disc bulge and facet arthropathy without significant spinal canal
or neural foraminal narrowing.
L2-L3: Minimal L3 superior corner retropulsion, mild disc bulge, and
mild-to-moderate facet arthropathy. No significant mass effect on the
intrathecal nerve roots. Mild narrowing of the subarticular zones without
frank compression of the traversing L3 nerve roots. Minimal neural foraminal
narrowing without exiting L2 nerve root impingement.
L3-L4: Mild disc bulge, larger on the right than left, and moderate facet
arthropathy. Mild narrowing of the subarticular zones without frank
compression of the traversing L4 nerve roots. No mass effect on the
intrathecal nerve roots. Minimal bilateral neural foraminal narrowing without
mass effect on the exiting L3 nerve roots.
L4-L5: Minimal disc bulge, infolding of the ligamentum flavum, and moderate
facet arthropathy. Mild narrowing of the left subarticular zone with contact
of the traversing left L5 nerve root, without evidence for frank compression.
No mass effect on the intrathecal nerve roots. No significant neural
foraminal narrowing.
L5-S1: Mild disc bulge with endplate osteophytes and moderate facet
arthropathy. Mild right and moderate left neural foraminal narrowing. No
significant spinal canal narrowing.
The above described degenerative changes are not significantly changed
compared to ___.
Degenerative changes of the partially imaged sacroiliac joints are again
noted.
OTHER:
Nonenlarged bilateral cervical lymph nodes, and multiple bilateral
supraclavicular lymph nodes measuring up to 12 mm on the right (14:20) and 9
mm on the left (14:23) are similar to the cervical spine MRI from ___, nonspecific in etiology.
There is a fluid level in the distal thoracic esophagus. Linear opacities in
the visualized portions of the lower lobes of the lungs are nonspecific but
statistically likely related to atelectasis or scarring.
On the localizer sequence image 4:6, the spleen measures 14 cm craniocaudad,
compared to 15 cm on the abdominal/pelvic CT from ___.
IMPRESSION:
1. Motion limited exam.
2. S/p laminectomies from T2 through T5. No evidence for recurrent epidural
collection in the cervical, thoracic, or lumbar spine. No evidence for
diskitis or osteomyelitis.
3. Unchanged multilevel degenerative disease in the cervical, thoracic, and
lumbar spine, as well as thoracic dorsal epidural lipomatosis, as detailed
above.
4. Splenomegaly is again partially imaged.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Other dorsalgia, Weakness
temperature: 97.8
heartrate: 99.0
resprate: 18.0
o2sat: 99.0
sbp: 157.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | ___ w/ past medical history of T2DM, HTN, HLD, chronic
pancreatitis, prior GBS bacteremia c/b T2-T6 epidural abscess
s/p decomp/laminectomy in ___ who presented with back pain
and symptoms of RLE weakness and LUE numbness. Patient underwent
extensive work up and evaluation by neurology and ortho spine
teams. MRI did not show any evidence of recurrent epidural
abscess. Etiology of her chronic back and abdominal pain are
unclear, but likely musculoskeletal pain.
TRANSITIONAL ISSUES
====================
[] Patient continues to have chest pain/back pain and would
benefit from outpatient pain clinic. Initial appointment has
been set up.
[] Patient would benefit from social work as outpatient as
patient has had multiple stressors.
[] Patient continues to have uncontrolled blood sugars. Please
refer patient to ___. Insulin was increased to 60
units of glargine BID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - ___ Catheter placement
___ - Cardioversion
History of Present Illness:
___ year old male with a PMH of HFrEF (Last LVEF 23% ___, LV
thrombus, VFib arrest s/p AICD placement (___ ___,
AFib/Aflutter s/p cardioversion and ablation (___ ___ who was
admitted with shortness of breath and insomnia. Pt had an
episode of syncope in ___, presumed from ventricular
arrhythmias; he was started on amiodarone for this. Over the
past few months, however, he has had progressive development of
nausea, insomnia, and paresthesias. These were thought to be
secondary to amiodarone, which was discontinued. One week ago,
he was seen by the clinic where they found weight gain of 2 lb,
an increase in Cr 1.4 (increased from 1.2) and persistent
insomnia (told to decrease torsemide from 20 to 10mg daily). He
presented in ___ 2 days ago refering worsening in his SOB
especially when coughing and insomnia.
On the floor, Pt was initially managed for CHF exacerbation with
IV furosemide, hydralazine, and a nitroglycerin drip. As he
continued to be cold and clammy, with a rise in lactate (to a
peak of 5) and persistent fatigue, he underwent a RHC which
showed CI 1.7, wedge pressure in the 30___, and a RAP of 20.
Given his persistent evidence of volume overload, Pt was
transferred to the CCU for initiation of nitroprusside gtt and
continued tailored therapy with furosemide gtt.
Vitals on transfer: T 99.9F BP 114/84 HR 90 RR 17 O2 98% on RA
On arrival to the CCU, Pt states that he is persistently
fatigued. He has pain at his ___ catheter insertion
site. He notes persistent lightheadedness and nausea with
hiccupping. He denies fevers, chills, CP, SOB, orthopnea,
abdominal pain, and vomiting.
Past Medical History:
1. CARDIAC RISK FACTORS
- Cocaine abuse, in remission
- Alcohol abuse, in remission
2. CARDIAC HISTORY
- Coronaries: No recent cath on file
- Pump: HFrEF (last LVEF 23%) with a previous LV thrombus
- Rhythm: Aflutter s/p ablation (___ ___
3. OTHER PAST MEDICAL HISTORY
- Depression
- Asthma
Social History:
___
Family History:
Parents passed away of unknown reasons. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ON ADMISSION:
VS: T 99.9F BP 114/84 HR 90 RR 17 O2 98% on RA
GENERAL: Heavyset ___ male, sitting up in bed with
R Swan catheter in place. Alert and oriented x3. Speaking
somewhat slowly but fluently.
HEENT: Sclerae anicteric. MMM.
NECK: Difficult to assess JVP due to habitus.
CARDIAC: Tachycardic with irregular rhythm, normal S1/S2. No
M/R/G.
LUNGS: Lungs CTAB.
ABDOMEN: Hypoactive bowel sounds. Abdomen is soft, somewhat
distended, non-tender to palpation throughout.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Radial pulses palpable and symmetric.
ON DISCHARGE:
Afebrile, 98.5 79-114/50-71 ___ 18 97-98%
I/O: ___
telemetry: no events NSR
Weight: 96.3 admit --> 87.6--> 85.5 -> 87.7 -> 88.1 -> 87.8
GEN: ___ male, lying in bed. Alert and oriented
x3.
NECK: JVP no seen at 45 degrees
CARDIAC: Regular rhythm, normal S1/S2. No M/R/G.
LUNGS: Lungs CTAB.
ABDOMEN: Abdomen is soft, somewhat distended, non-tender to
palpation throughout.
EXTREMITIES: Warm, well perfused proximally. No clubbing,
cyanosis, or peripheral edema.
Pertinent Results:
ADMISSION LABS
=================
___ 02:15PM GLUCOSE-106* UREA N-18 CREAT-1.4* SODIUM-131*
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-23 ANION GAP-18
___ 02:15PM ALT(SGPT)-142* AST(SGOT)-102* ALK PHOS-141*
TOT BILI-3.0* DIR BILI-0.9* INDIR BIL-2.1
___ 02:15PM cTropnT-<0.01
___ 02:15PM proBNP-8655*
___ 02:15PM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-4.2
MAGNESIUM-2.1
___ 02:15PM WBC-5.2 RBC-3.66* HGB-11.2* HCT-34.2* MCV-93
MCH-30.6 MCHC-32.7 RDW-15.0 RDWSD-51.7*
___ 02:15PM NEUTS-65.2 ___ MONOS-12.3 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-3.41 AbsLymp-1.12* AbsMono-0.64
AbsEos-0.03* AbsBaso-0.01
___ 02:15PM PLT COUNT-167
___ 02:10PM URINE HOURS-RANDOM
___ 02:10PM URINE UHOLD-HOLD
___ 02:10PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
___ 02:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:10PM URINE HYALINE-54*
___ 02:10PM URINE MUCOUS-RARE*
Cardiac Cath ___
Elevated biventricular filling pressures with cardiogenic shock
CXR ___
Cardiomegaly without superimposed acute cardiopulmonary process.
RUQUS ___. The liver is mildly echogenic diffusely, likely steatosis.
2. Distension of the IVC and hepatic veins likely due to cardiac
disease.
3. Multiple hepatic cysts, the largest measuring 2.2 cm in the
right hepatic lobe.
Radiology Report
INDICATION: ___ with a fib and chest pain// Chest pain
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Heart is moderately enlarged. Left chest wall single lead pacing device is
noted. Nodular opacity projecting over left lung base described on prior is
not as well seen on today's exam. Bibasilar atelectasis is noted. No acute
osseous abnormalities.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with swan// swan placement and pulm edema
TECHNIQUE: Chest, single AP portable view.
COMPARISON: Chest x-rays from 6 ___, ___, and ___.
FINDINGS:
A right IJ ___-___ catheter is present. The tip overlies the proximal right
pulmonary artery. No pneumothorax detected.
Left-sided pacemaker is present, with lead tip overlying the right ventricle.
There is moderate to moderately severe cardiomegaly,, unchanged.
There is upper zone redistribution, without other evidence of CHF. Hazy
increased retrocardiac density likely reflects atelectasis. Minimal
subsegmental atelectasis is also seen in the right mid and lower zones. No
gross effusion. No pneumothorax detected.
Again seen is a nodular density lying lateral to the left heart border. On
some views, the appearance is suggestive of a nipple shadow.
IMPRESSION:
Moderate cardiomegaly and bibasilar atelectasis.
Pacemaker lead overlying the right ventricle.
___ catheter tip overlying proximal right pulmonary artery.
Upper zone redistribution. Doubt other evidence of CHF.
Nodular density in left lower lung laterally again noted, possibly a nipple
shadow, as questioned on the previous film. However, repeat frontal, lateral
and shallow oblique chest x-ray views with nipple markers is recommended for
confirmation. This can be obtained as a non urgent study.
RECOMMENDATION(S): Frontal, lateral, and shallow oblique chest x-ray views
with nipple markers is recommended for more complete characterization of the
nodular density in the left lower lung laterally. This can be obtained as a
non urgent study, when the patient is stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF exacerbation, Swan in place// Interval
change in pulm edema, effusions. Swan placement
TECHNIQUE: Chest, single AP portable view
COMPARISON: Chest x-ray from ___, and ___.
FINDINGS:
The cardiomediastinal silhouette is unchanged. Again seen is moderately
severe to severe chronic cardiomegaly. A left-sided single lead pacemaker is
present, with tip over right ventricle, similar to prior.
A right IJ Swan-Ganz catheter tip overlies the pulmonary outflow tract near
the main pulmonary artery. No pneumothorax is detected.
There is mild upper zone redistribution and engorgement of hilar vessels, but
doubt other evidence of CHF. Vascular engorgement is similar, possibly
minimally improved compared with ___.
Probable mild atelectasis in the retrocardiac region, unchanged. Otherwise,
no focal infiltrate/consolidation no effusion.
Again seen is a nodular density in the left lung laterally, adjacent to the
left heart border. Please see report of ___ chest x-ray for
recommendations for additional assessment.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis// Patient with swan and drips
cannot go off of the floor. LFT's trending in different direction compared to
CHF.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound from ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites. There are multiple anechoic cysts seen throughout
the liver, the largest measuring up to 2.2 cm in the right hepatic lobe.
There is enlargement of the IVC and hepatic veins.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 8.0 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. The liver is mildly echogenic diffusely, likely steatosis.
2. Distension of the IVC and hepatic veins likely due to cardiac disease.
3. Multiple hepatic cysts, the largest measuring 2.2 cm in the right hepatic
lobe.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Cough, Weakness
Diagnosed with Heart failure, unspecified
temperature: 97.3
heartrate: 63.0
resprate: 18.0
o2sat: 96.0
sbp: 101.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old male with a PMH of HFrEF (Last LVEF
23% ___, LV thrombus, VFib arrest s/p AICD placement (___
___, AFib/Aflutter s/p cardioversion and ablation (___
___ was admitted for insomnia as a potential side effect of
amiodarone use. On admission he was noted to be wet and cold.
RHC showed cardiac index of 1.7 and his lactate was elevated to
5. He was transferred to the CCU for Swan directed diuresis and
IV afterload reducing agents. In the CCU, he underwent
successful DCCV of his atrial fibrillation to sinus rhythm. He
was started on digoxin and torsemide 40 twice daily. The patient
was started on Spironolactone, imdur and hydralazine. He was
kept on his apixaban and lisinopril. After stabilization in the
ICCU the patient was transferred to the ward where he was
further diuresed with P.O. diuretics. Diuretics were eventually
held as the patient was dry and had some episodes of
hypotension. The patient was started on low-dose of metoprolol
to be uptitrated as an outpatient.
We re-emphasized that because the patient had an electrical
shock from your ICD in ___, he should avoid driving and/or
operating heavy machinery for a period up to 6 months due to
increase risk of harm to yourself and/or others.
On the day of discharge the patient was in sinus rhythm was dry
and warm with no signs of congestion.
# Discharge weight: 87.9 kg. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / clindamycin / doxycycline
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a background history of type II DM, HTN,
hyperparathyroidism status post exploration and
parathyroidectomy, breast cancer status post surgical,
radiotherapy and hormonal treatment, and osteoporosis,
presenting
as a transfer from ___ following an episode of syncope
at
home, and two further witnessed episodes, one in the ambulance
on
route to ___, and one while in ___.
Patient was in her normal state of health when she awoke this
morning. When stepping out of shower, had a sudden loss of
consciousness, with no warning symptoms, except for some mild
light-headedness. Denied chest pain, shortness of breath,
nausea/vomiting, visual changes, and headache. Fell to the
ground, landing on her right hip and arm. Denied tongue biting
and incontinence, but unable to comment on limb jerking as no
one
witnessed episode. Unclear duration of loss of consciousness.
Feels she may have struck her head as awoke on the ground, and
did report low back and right hip pain upon waking. Reported
"fogginess" and headache post event, with difficulty recalling
events. Spoke with daughter (RN) and PCP, who recommended
presenting to ED. On route to ___, had a second syncopal
episode while seated in the car, during a sudden turn. Again,
denies warning symptoms, except for some "wooziness" prior to
syncopal episode. Husband reports episode lasted ___ secs,
with
eyes open and staring up and to the left throughout. ___ have
had
some twitching of left sided extremities, but no definitive
jerking. At ___, patient had a third syncopal episode as
she was being transferred from the stretcher to the CT scanner.
Unclear duration of event.
At ___, she underwent a complete trauma work-up,
including imaging of the hip, head and C-spine, all of which
were
negative for traumatic injury. The patient was transferred to
___ for further syncope workup, given concern for arrhythmia
as
a likely cause for these events.
Past Medical History:
1. Type II DM
2. HTN
3. Previous TIA vs. migraine
4. Anxiety
5. Osteoporosis
6. Hyperparathyroidism status post neck exploration and
parathyroidectomy
7. Herpes gingivostomatitis
8. GERD
9. Breast cancer status post lumpectomy and left axillary
lymphadenectomy (___), radiotherapy (___) and now on
hormonal treatment
Social History:
___
Family History:
Father with MI at ___ years old. Mother and maternal aunt with a
history of breast cancer. Maternal grandmother with a history of
ovarian cancer.
Physical Exam:
ADMISSION EXAM
============================
VS: Temp 98.3 BP 143/84 HR 63 RR 18 SaO2 96% RA
GENERAL: sitting comfortably in bed, no apparent distress
HEENT: AT/NC, EOMI, PERRLA, no conjucntival pallor, anicteric
sclera, MMM
NECK: supple, non-tender, no LAD, no JVD
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheeze/crackles, breathing comfortably without
use
of accessory muscles of respiration
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: moving all four extremities with purpose, no lower
extremity edema or cyanosis
SKIN: no rashes/lesions
NEURO: A/O x3, CN II-XII intact, strength ___ in all
extremities,
sensation intact
DISCHARGE EXAM
============================
Vitals: Temp: 98.0 PO HR: 59 BP: 130/79 RR: 18 O2 sat: 98% O2
delivery: Ra
General: Well appearing woman in no acute distress. Comfortable.
AAOx3.
Neuro: CNII-XII grossly intact. Speech normal. Strength ___ and
equal in upper and lower extremities bilaterally. Sensation
grossly intact.
HEENT: Normocephalic, atraumatic. EOMI. MMM.
Cardiac: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs,
or gallops.
Pulmonary: Clear to auscultation bilaterally. Breathing
comfortably on room air.
Abdomen: Soft, non-tender, non-distended.
Extremities: Warm, well perfused, non-edematous.
Pertinent Results:
ADMISSION LABS
==========================
___ 06:45AM BLOOD WBC-5.2 RBC-3.96 Hgb-11.8 Hct-36.1 MCV-91
MCH-29.8 MCHC-32.7 RDW-12.9 RDWSD-42.3 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-125* UreaN-10 Creat-0.5 Na-142
K-4.4 Cl-104 HCO3-24 AnGap-14
___ 02:40PM BLOOD K-4.4
___ 02:40PM BLOOD cTropnT-<0.01
___ 02:40PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.5*
DISCHARGE LABS
==========================
___ 06:35AM BLOOD WBC-4.9 RBC-3.96 Hgb-11.8 Hct-36.3 MCV-92
MCH-29.8 MCHC-32.5 RDW-12.7 RDWSD-42.7 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-125* UreaN-10 Creat-0.5 Na-143
K-4.6 Cl-105 HCO3-22 AnGap-16
___ 06:35AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.3
PERTINENT STUDIES
=========================
X-RAY HAND/WRIST (___)
No acute fracture or dislocation.
TTE (___)
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional/global systolic function. Mild mitral
regurgitation.
MRI HEAD (___)
1. No evidence for acute intracranial hemorrhage or infarction.
No abnormal
enhancement to suggest intracranial metastatic disease.
2. Evidence of chronic small vessel ischemic disease.
CTA HEAD/NECK (___)
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
large territory infarct or intracranial hemorrhage.
2. Mild narrowing of the distal segment of the right vertebral
artery.
Otherwise, the carotid and vertebral arteries, and their
principal
intracranial branches are unremarkable, without evidence of
high-grade
stenosis or occlusion.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Anastrozole 1 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO QPM
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO EVERY OTHER DAY
9. Montelukast 10 mg PO DAILY
10. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Anastrozole 1 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO QPM
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO EVERY OTHER DAY
9. Vitamin D ___ UNIT PO DAILY
10. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until your primary care physician
tells you to start it again.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
============
Syncope
Secondary:
============
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pain and swelling after fall//r/o fracture
COMPARISON: None
FINDINGS:
AP, lateral, oblique views of the right hand, right wrist and a dedicated
navicular view provided. The distal radius and ulna are intact. The carpals
align anatomically. The scaphoid appears intact. The bones of the right hand
appear intact. No significant DJD. Soft tissues appear grossly unremarkable.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ with hx breast cancer with multiple syncopal episodes
concerning for seizure// mass or other cause for possibly new onset seizures?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of acute infarction. No intracranial hemorrhage. No
mass, mass effect, edema or midline shift.
There is no abnormal enhancement. The dural venous sinuses appear patent.
The ventricles and sulci are normal, without evidence of hydrocephalus.
Periventricular and subcortical white matter FLAIR hyperintensities are noted,
a nonspecific finding that most likely represents the sequelae of chronic
small vessel ischemic disease. There is gross preservation of the principal
intracranial vascular flow voids.
Mild mucosal thickening is seen in scattered ethmoid air cells. The remainder
of the visualized paranasal sinuses, middle ear cavities, and mastoid air
cells are well aerated and clear. The orbits are within normal limits
bilaterally.
IMPRESSION:
1. No evidence for acute intracranial hemorrhage or infarction. No abnormal
enhancement to suggest intracranial metastatic disease.
2. Evidence of chronic small vessel ischemic disease.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ woman with unclear cause for new syncope. Please
evaluate for vascular abnormalities to explain 3 syncopal episodes.
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 75 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Spiral Acquisition 4.5 s, 35.8 cm; CTDIvol = 13.3 mGy (Body) DLP = 474.8
mGy-cm.
3) Stationary Acquisition 4.6 s, 0.5 cm; CTDIvol = 27.1 mGy (Body) DLP =
13.5 mGy-cm.
Total DLP (Body) = 488 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: CT of the head and neck from ___. Head MR from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territory infarction, intracranial
hemorrhage, edema, or mass effect. Very minimal nonspecific white matter
hypodensities probably represent sequela of chronic small vessel disease.
There is prominence of the ventricles and sulci, probably related involutional
changes.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
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:
Suboptimal visualization at the level of C2 due to artifact from dental
fillings. Within this limitation, the distal segment of the right vertebral
artery appears slightly narrowed. Otherwise, the carotid and vertebral
arteries and their major branches appear unremarkable. There is no evidence
of internal carotid artery stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs demonstrate bilateral atelectasis. The
thyroid gland is slightly inhomogeneous and several small nodules are noted,
not meeting ACR guidelines for follow-up. There is no lymphadenopathy by CT
size criteria. Multilevel degenerative changes in the cervical spine.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territory infarct or intracranial hemorrhage.
2. Mild narrowing of the distal segment of the right vertebral artery.
Otherwise, the carotid and vertebral arteries, and their principal
intracranial branches are unremarkable, without evidence of high-grade
stenosis or occlusion.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.4
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 139.0
dbp: 76.0
level of pain: 2
level of acuity: 2.0 | ___ woman with PMHx notable for type II diabetes,
hypertension, hyperparathyroidism s/p exploration and
parathyroidectomy, breast cancer s/p surgical, radiotherapy, and
hormonal treatment, and osteoporosis presented for syncope x3
episodes over course of 1 day. Primarily concerning for
arrhythmia event, however symptoms did not recur and no findings
captured on continuous telemetry. Patient underwent additional
extensive neurological workup as detailed below. Given
resolution of symptoms and unremarkable workup, was discharged
home with plan for long term cardiac monitor and EP follow up.
Patient advised to not drive for at least 6 months.
# SYNCOPE / FALL
Referred from ___ following three episodes of syncope
that occurred over course of a single day. First with associated
fall and head strike without significant injury. Reported onset
of unusual feeling coming over her body, then sudden loss of
consciousness lasting on order of seconds to minute. Initially
un-witnessed, later seen by her husband and hospital staff (in
CT scanner during third episode) to have loss of tone but
without any significant tonic-clonic motions. No tongue biting
or incontinence. Overall clinical presentation most concerning
for arrhythmia, however no episodes captured on cardiac
monitoring. Episodes did not recur while at ___. Workup
notable for EKG with T-wave inversions in V1 and V3 and 1mm
ST-depressions in anterior leads, though not necessarily related
and unclear if new. No chest pain and negative troponins.
Initial CT head and C-spine without acute process. MRI brain
only with chronic small vessel changes, no mass lesions. CTA
head and neck prelim read without vascular cause identified.
Continuous EEG monitoring x24h without epileptiform findings.
Carotid sinus massage produced mild "woozy" feeling though did
not re-produce episodes or have associated telemetry findings.
TTE with mild concentric LVH though otherwise reassuring. Lyme
titer sent at outside hospital was negative. Of note, patient
was normotensive off of home antihypertensive (lisinopril), so
concern for possible hypotensive episodes. Given that no
definitive cause was identified patient was discharged with plan
for long term cardiac event monitor which will be mailed to her
home. Also scheduled to follow up with outpatient cardiology for
further management.
# DIABETES
- held metformin during hospitalization only, used insulin
sliding scale
# ANXIETY
- continued citalopram
# HTN
- HELD lisinopril as patient remained normotensive throughout
hospitalization
# OSTEOPOROSIS
- continue calcium and vitamin D
# GERD
- continue omeprazole every other day
TRANSITIONAL ISSUES
=================================
[ ] Cardiac monitoring to be completed as outpatient. Per
cardiology event monitor will be mailed to her home.
[ ] HELD lisinopril at time of discharge, given normotensive
throughout hospital stay, and possible contribution. Please
re-check BP and assess need for re-treatment.
[ ] Patient was directed to not drive for at least 6 months.
Please re-affirm this at time of follow up.
#CONTACT: ___ (husband: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Nsaids / lisinopril / Lipitor / carvedilol /
tramadol / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with CAD s/p PCI, HFrEF, AF
on
Coumadin, ESRD on HD, Depression, HTN, HLD, Lupus who presented
with dizziness and hypotension, being admitted to the ___ for
low-dose pressor requirement.
2 weeks ago, she feel while at a relative's home and was found
to
have a L shoulder fracture and R shoulder dislocation for which
she was given oxycodone. Since starting the oxycodone, she has
had constant lightheadedness and dizziness with nausea and
subsequent very poor oral intake.
She went to HD today and prior to the session was noted to have
SBP in the ___ and was noted to be febrile (temperature
unclear).
She was given 600c IV and referred to the ED without getting her
HD session.
In the ED,
- Initial Vitals: T 99.7, HR 118, BP 90/46, RR 22, O2 96%2L
- Exam: Comfortable, normal level of alertness, JVP flat. Rectal
exam with guaiac negative brown stool. ___ warm, well-perfused.
- Labs: Notable for WBC 10.6, INR 3.4, Flu neg.
- Imaging: CXR unremarkable, bedside US with moderately
decreased
EF and nl RV
- Consults: None
- Interventions: Vancomycin 1g, Cefepime 1g, Hydrocortisone
100mg, NS 1L, Levophed 0.1 mcg/kg/min
On arrival to the ___, she reports that she feels a bit better
from earlier. She is no longer dizzy. Denies any difficulty
breathing. She denies any recent cough, difficulty breathing,
chest pain, abdominal pain, vomiting, congestion, headache. She
had 2 days of unformed stools ___, but after stopping bowel
regimen has had normal BMs. She does not make any urine. No sick
contacts.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- SLE c/b lupus nephritis (s/p renal transplant ___ c/b failure
now on HD
- HFrEF ___ ischemic cardiomyopathy
- CAD s/p NSTEMI with pLAD occlusion, s/p BMS ___, DES to
pRCA
___
- HTN
- Pericarditis with pericardial effusion
- Atrial Flutter
- TIA ___
- Rheumatic Fever as a child
- Gout
- Sleep apnea, on CPAP
- Depression
- Osteoporosis
Social History:
___
Family History:
- Former ___, lives with husband & ___ year-old
daughter. Not working but prior to her fall was able to do all
her ADLs (laundry, cooking, cleaning). Had 1 glass of wine when
on the ___ but very infrequent EtOH intake.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 99.3, HR 92, BP 102/33, RR 16, O2 95%2L
GEN: Well-appearing but weak, lying in bed, AOx3.
EYES: PERRL
HENNT: NC/AT. MMM. No pharyngeal edema or erythema.
CV: NR, RR. Nl S1, S2. No m/r/g.
RESP: CTAB.
GI: Soft, nontender, nondistended.
MSK: No ___ edema. Warm, well-perfused.
SKIN: No rashes, macules, skin breaks.
NEURO: AOx3.
DISCHARGE PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 334)
Temp: 97.9 (Tm 98.9), BP: 102/68 (102-119/68-73), HR: 83
(83-116), RR: 18, O2 sat: 99% (93-99), O2 delivery: CPAP
Weight 87.54kg
Gen - sitting up in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds
Ext - L arm in sling, point pain over shoulder joint;
Skin - no rashes
Vasc - 2+ DP pulses; L fistula c/d/i
Neuro - AOx3, moving all extremities; RUE decreased strength of
finger and wrist flexion consistent with known ulnar nerve
palsy,
stable from day prior
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:35AM BLOOD WBC-10.6* RBC-2.55* Hgb-8.8* Hct-27.9*
MCV-109* MCH-34.5* MCHC-31.5* RDW-15.4 RDWSD-61.5* Plt ___
___ 11:35AM BLOOD ___ PTT-34.7 ___
___ 11:35AM BLOOD Glucose-103* UreaN-11 Creat-2.5*# Na-135
K-4.2 Cl-93* HCO3-29 AnGap-13
___ 11:15PM BLOOD ALT-64* AST-98* LD(LDH)-246 AlkPhos-121*
TotBili-0.3
DISCHARGE
___ 06:41AM BLOOD WBC-4.6 RBC-2.33* Hgb-8.0* Hct-26.8*
MCV-115* MCH-34.3* MCHC-29.9* RDW-15.4 RDWSD-64.9* Plt ___
___ 06:41AM BLOOD Glucose-84 UreaN-13 Creat-4.0*# Na-143
K-4.5 Cl-102 HCO3-30 AnGap-11
___ 06:41AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.4
IMAGING:
==========
___ CXR
Limited, negative.
___ HUMERUS (AP & LAT) LEFT
Comminuted fracture at the level of the left humeral surgical
neck with
displacement of the greater tuberosity.
___ SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA BILAT
Comminuted fracture involving the surgical neck of the left
humerus with
displacement of the greater tuberosity. The right shoulder is
unremarkable.
___
Mild regional left ventricular systolic dysfunction, c/w CAD.
Moderate aortic stenosis. Mild aortic and mitral regurgitation.
The visually estimated left ventricular ejection fraction is
50%. Compared with the prior TTE (images not available for
review) of ___, LV systolic function has improved.
___ CT UP EXT W/O C RIGHT
Comminuted fracture of the left proximal humerus with fracture
displacement at the surgical neck and greater tuberosity.
Findings are compatible with a Neer three part fracture.
___ CT UP EXT W/O C LEFT
1. Regularity superolateral humeral head consistent with
___ deformity likely related to prior anterior shoulder
dislocation. There is no current glenohumeral joint
dislocation.
2. High-grade tear of the supraspinatus tendon tendon
retraction and
calcification within the free edge of the tendon likely
representing avulsion injury.
3. Mild irregularity of the anterolateral aspect of the humeral
head next the bicipital groove, suspicious for subacute
fracture.
___ LIVER OR GALLBLADDER US
1. No specific evidence of cirrhosis or portal hypertension.
No focal liver lesions or ascites.
2. Biliary sludge within the gallbladder without evidence of
cholecystitis.
___ CHEST (PORTABLE AP)
In comparison with the study of ___, there is little
interval change. Again there are low lung volumes that
accentuate the prominence of the cardiac silhouette. No
vascular congestion or acute focal pneumonia. The implanted
rhythm monitor is again noted within the lower left chest wall.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. acitretin 10 mg oral DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.5 mcg PO 3X/WEEK (___)
5. Calcium Acetate ___ mg PO TID W/MEALS
6. Mirtazapine 15 mg PO QHS
7. PredniSONE 3 mg PO DAILY
8. Prochlorperazine 5 mg PO Q8H:PRN nausea
9. rOPINIRole 2 mg PO QPM
10. Rosuvastatin Calcium 40 mg PO QPM
11. Tacrolimus 0.5 mg PO Q12H
12. Warfarin 3.75-5 mg PO DAILY16
13. Zolpidem Tartrate 5 mg PO QHS
14. Losartan Potassium 12.5 mg PO 4X/WEEK (___)
15. Metoprolol Succinate XL 12.5 mg PO 3X/WEEK (___)
16. B Complex w-Vit C (vit B1 mn-B2-B3-B5-B6-B12-C-FA)
___ mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Gabapentin 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Midodrine 5 mg PO TID
5. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*6 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO BID
7. Senna 17.2 mg PO BID
8. Warfarin 3 mg PO DAILY16
9. acitretin 10 mg oral DAILY
10. Allopurinol ___ mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. B Complex w-Vit C (vit B1 mn-B2-B3-B5-B6-B12-C-FA)
___ mg oral DAILY
13. Calcitriol 0.5 mcg PO 3X/WEEK (___)
14. Calcium Acetate ___ mg PO TID W/MEALS
15. Mirtazapine 15 mg PO QHS
16. PredniSONE 3 mg PO DAILY
17. Prochlorperazine 5 mg PO Q8H:PRN nausea
18. rOPINIRole 2 mg PO QPM
19. Rosuvastatin Calcium 40 mg PO QPM
20. Tacrolimus 0.5 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Adrenal insufficiency
# Hypotension
# L shoulder fracture
# ESRD on HD
# Paroxysmal Atrial Flutter
# OSA
# Depression
# Chronic systolic CHF
# CAD
# Gout
# Restless leg 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: CHEST (PORTABLE AP)
INDICATION: ___ with hypotension, fever// PNA? signs of vol overload?
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior comparisons, most recent from ___
FINDINGS:
Exam is mildly limited due to patient rotation. Implanted rhythm monitor is
again noted within the lower left chest wall.
Lung volumes are low. Bronchovascular markings are prominent the lower lungs
likely due to crowding. No convincing evidence for pneumonia or edema. No
large effusion or pneumothorax. Overall cardiomediastinal silhouette is
stable allowing for rotation.
IMPRESSION:
Limited, negative.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA BILATERAL
INDICATION: ___ year old woman with reported R shoulder dislocation and L
humerus fracture// fracture? dislocation?
TECHNIQUE: Three views of each shoulder were obtained
COMPARISON: ___
FINDINGS:
The right shoulder is unremarkable with no acute fracture or significant
degenerative change.
The left shoulder demonstrates a comminuted fracture involving the surgical
neck and displacement of the greater tuberosity. There is no significant
impaction or angulation. There is no dislocation.
IMPRESSION:
Comminuted fracture involving the surgical neck of the left humerus with
displacement of the greater tuberosity.
The right shoulder is unremarkable.
Radiology Report
EXAMINATION: HUMERUS (AP AND LAT) LEFT
INDICATION: ___ year old woman with reported R shoulder dislocation and L
humerus fracture// fracture?
TECHNIQUE: Three views of the left humerus were obtained
COMPARISON: Radiograph of the left shoulder from earlier today
FINDINGS:
Re-demonstrated is a comminuted fracture of the left humeral surgical neck
with a displaced greater tuberosity. No significant impaction or angulation.
No additional fractures are identified.
IMPRESSION:
Comminuted fracture at the level of the left humeral surgical neck with
displacement of the greater tuberosity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypotension// interval change
IMPRESSION:
In comparison with the study of ___, the cardiomediastinal silhouette
is stable a and there is no evidence of vascular congestion, pleural effusion,
or acute focal pneumonia. The implanted rhythm monitor is again noted within
the lower left chest wall.
Radiology Report
EXAMINATION: Q51R
INDICATION: ___ year old woman ESRD with R shoulder dislocation s/p reduction
comminuted L proximal humeral fracture.// Eval shoulders for ortho
consideration of surgery
TECHNIQUE: Multiple contiguous 2 mm axial images were obtained through the
left shoulder without the administration of intravenous contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 22.9 cm; CTDIvol = 30.6 mGy (Body) DLP = 679.0
mGy-cm.
Total DLP (Body) = 679 mGy-cm.
COMPARISON: Compared to radiographs from ___.
FINDINGS:
There is a comminuted fracture of the left proximal humerus. Fracture lines
are seen at the surgical neck with some impaction. There is also displaced
fracture at the greater tuberosity. The lesser tuberosity appears intact.
Findings are consistent with a Neer three part fracture. The rest of the bony
structures are intact. There is no glenohumeral joint dislocation.
The supraspinatus remains attached to the greater tuberosity fracture fragment
which is displaced medially. AC joint is within normal limits. Visualized
lung apex is grossly clear.
IMPRESSION:
Comminuted fracture of the left proximal humerus with fracture displacement at
the surgical neck and greater tuberosity. Findings are compatible with a Neer
three part fracture.
Radiology Report
EXAMINATION: Q51L
INDICATION: ___ year old woman s/p fall ___ days ago w/ R shoulder anterior
dislocation s/p reduction; L shoulder comminuted humeral fracture.// Eval for
fracture.
TECHNIQUE: Multiple contiguous 2 mm axial images were obtained through the
right shoulder without the administration intravenous contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 24.9 cm; CTDIvol = 30.6 mGy (Body) DLP = 740.2
mGy-cm.
Total DLP (Body) = 740 mGy-cm.
COMPARISON: Compared to the right shoulder radiographs from ___
FINDINGS:
There is no glenohumeral joint dislocation. There is a ___ deformity
of the superolateral humeral head consistent with prior anterior shoulder
dislocation. There is slight irregularity along the lateral aspect of the
bicipital groove, best seen on series 4, image 27, suspicious for a subacute
fracture.
There is mild irregularity of the AC joint.
The subacromial interval is narrowed and there is likely a high-grade tear of
the supraspinatus tendon. There is a 6 mm calcification within the distal
tendon suspicious for an avulsion injury. This is best seen on series 7,
image 39.
Visualized right lung apex is grossly clear.
IMPRESSION:
1. Regularity superolateral humeral head consistent with ___ deformity
likely related to prior anterior shoulder dislocation. There is no current
glenohumeral joint dislocation.
2. High-grade tear of the supraspinatus tendon tendon retraction and
calcification within the free edge of the tendon likely representing avulsion
injury.
3. Mild irregularity of the anterolateral aspect of the humeral head next the
bicipital groove, suspicious for subacute fracture.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year-old woman with CAD s/p PCI, HFrEF, AF on Coumadin, ESRD
on HD, Depression, HTN, HLD, Lupus who presented with dizziness and
hypotension, being admitted to the FICU for low-dose pressor requirement. Low
albumin and LFTs abnormal so questionable cirrhosis causing vasoplegia
contribution?// cirrhotic liver?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Correlation is made to CT chest ___.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. 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: 6 mm
GALLBLADDER: Gallbladder sludge 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: 10.3 cm
KIDNEYS: The kidneys were not well visualized. Patient is status post renal
transplant.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No specific evidence of cirrhosis or portal hypertension. No focal liver
lesions or ascites.
2. Biliary sludge within the gallbladder without evidence of cholecystitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman p/w hypotension, now newly septic looking for
source.// sepsis, ?PNA
IMPRESSION:
In comparison with the study of ___, there is little interval change.
Again there are low lung volumes that accentuate the prominence of the cardiac
silhouette. No vascular congestion or acute focal pneumonia.
The implanted rhythm monitor is again noted within the lower left chest wall.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension
Diagnosed with Hypotension, unspecified
temperature: 99.7
heartrate: 118.0
resprate: 22.0
o2sat: 96.0
sbp: 90.0
dbp: 46.0
level of pain: 4
level of acuity: 2.0 | This is a ___ year old female with past medical history of CAD,
systolic CHF, OSA on CPAP, paroxysmal atrial flutter with prior
stroke, SLE complicated by lupus nephritis, on HD, prior chronic
hypotension requiring outpatient midodrine, titrated off of this
medication within the last ___ year, with a recent fall with
resulting R shoulder dislocation and L shoulder fracture,
subsequently admitted ___ with worsening dizziness and
hypotension, with extended hospital course notable for negative
infectious workup, persistent hypotension requiring midodrine,
subsequent clinical improvement
# Hypotension
# Adrenal insufficiency
Patient admitted to ICU after presenting with hypotension.
Patient IV fluid resuscitated and initiated on intravenous
vasopressors. Workup yielded no signs of clear infectious
etiology. Outside of fractures, dislocations (mentioned below),
exam and review of systems was without localizing findings. TTE
showed partially recovered EF to 50% without any changes. Given
concern for adrenal insufficiency, she received several days of
stress dose steroids with Hydrocort 50mg Q6H. Given patient's
history of borderline-low blood pressures requiring previous
midodrine (which had been discontinued over recent ___ year), she
was restarted on midodrine. Subsequent and cosyntropin test was
felt to demonstrate adequate adrenal reserve at that time.
Based on endocrine service evaluation and clinical picture,
perhaps hypotension related to brief adrenal insufficiency (the
result of ___ years of sub-physiological prednisone dosing
suppressing ACTH) in setting of stress of her fall, fractures
and dislocation, which resolved with her stress dose steroids
and resolving stress of her acute illness. Patient was returned
to her chronic prednisone dose, and midodrine was weaned from
15mg TID to 5mg TID by time of discharge. Anticipate this may
be able to be weaned further and discontinued over next ___
months (this is of importance given that it impacts her
transplant listing). Had multidisciplinary discussion between
endocrine, nephrology, and cardiology who felt risk/benefit
would not favor trial of fludrocortisone.
# s/p Fall with R shoulder dislocation, L shoulder fracture
2 weeks prior to admission, she fell while at a relative's home
and was found to have a L shoulder fracture and R shoulder
dislocation. On admission here, orthopedics was consulted,
recommended repeat imaging which confirmed a comminuted left
proximal humerus with fracture displacement at the surgical neck
and greater tuberosity compatible with a Neer three part
fracture. She had a high-grade tear of the R supraspinatus
tendon tendon with retraction and calcification within the free
edge of the tendon likely representing avulsion injury and
concern for subacute fracture of the humeral head. Of note, the
CTs were labeled incorrectly, radiologist who read the studies
was contacted regarding this. She was treated with standing
Tylenol, Gabapentin, prn oxycodone (kept on low doses because
her blood pressure was sensitive to this). Orthopedic
recommendations:
- NWB LUE in sling, OK for pendulums, OK for passive range of
motion to the level of the shoulder with ___
- WBAT RUE, sling for comfort, range of motion as tolerated
Discharged with follow-up with Dr. ___ ___.
# ESRD on HD
Continued on tacrolimus, Calcitriol. Continued HD MWF. Given
hypotension (above), goal weight was increased to 86kg.
Discharge weight = 86.5kg.
# A flutter
# Supratherapeutic INR
Had variable INR this admission requiring adjustment of Coumadin
dosing. At discharge patient was on warfarin 3mg daily, INR
2.2. Would recheck INR on ___ at rehab, adjust dosing for goal
INR ___.
# OSA
Continued CPAP QHS
# Depression
Continued Mirtazapine
# Chronic systolic CHF
# CAD
Continued statin, ASA. Given hypotension, held metoprolol and
losartan. Volume management with HD. Goal standing weight =
86kg
# Gout
Continued Allopurinol
# Restless leg syndrome
Continued rOPINIRole
# Constipation
While on oxycodone, was started on bowel regimen with miralax
and senna
# History of skin cancer
Held acitretin during admission, restarted at 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:
Abd pain
Major Surgical or Invasive Procedure:
___ attempted ___ drainage of pericolonic fluid collection,
aborted
History of Present Illness:
___ with longstanding h/o recurrent prostatitis presented
initially with sx c/w prostatitis starting last ___. Reports
having difficulty urinating, fevers/chills. He went to his PCP
on
___ for persistent symptoms and was prescribed Bactrim, but
returned on ___ with persistent symptoms despite the
antibiotics. He was prescribed Cipro at this point, which still
did not improve his symptoms, so he had a non-con CTAP done
showing possible diverticulitis, so he was referred to ___
___
where he underwent another CT, this time with contrast, which
demonstrated diverticulitis and concern for abscess and possible
vesicular fistula. He was started on antibiotics at ___
prior to being transferred to ___ for surgical evaluation.
Has had 2 colonoscopies in the past, most recently in ___, with
diverticulosis but otherwise unremarkable.
Past Medical History:
Past Medical History:
CLL (never treated, in remission), h/o proctitis (reports
initial attacks beginning ___ ago, treated several times
with prolonged courses of antibiotics, last episode ___ ago),
h/o kidney stones
Past Surgical History:
Tonsillectomy
Social History:
___
Family History:
Father with diverticulitis
Physical Exam:
Vitals: 98 60 112/72 18 99RA
Gen: AAOx3 NAD comfortable
CV: NRRR
Chest: CLAB
Abd: Soft, mildly ttp in lower quadrants but significantly
improving from previous. No guarding or organomegaly. No hernias
or masses.
Extrem: Without deformity or edema
Pertinent Results:
___ 07:08AM BLOOD WBC-21.7* RBC-4.03* Hgb-12.3* Hct-36.7*
MCV-91 MCH-30.5 MCHC-33.5 RDW-12.4 RDWSD-41.2 Plt ___
___ 05:45AM BLOOD WBC-24.6* RBC-3.60* Hgb-11.2* Hct-33.4*
MCV-93 MCH-31.1 MCHC-33.5 RDW-12.5 RDWSD-42.4 Plt ___
___ 05:20AM BLOOD WBC-26.7* RBC-3.60* Hgb-11.3* Hct-33.3*
MCV-93 MCH-31.4 MCHC-33.9 RDW-12.5 RDWSD-42.6 Plt ___
___ 12:45AM BLOOD WBC-31.0* RBC-3.76* Hgb-11.7* Hct-34.5*
MCV-92 MCH-31.1 MCHC-33.9 RDW-12.5 RDWSD-42.3 Plt ___
___ 12:45AM BLOOD Neuts-27* Bands-1 Lymphs-66* Monos-3*
Eos-0 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-8.68*
AbsLymp-21.39* AbsMono-0.93* AbsEos-0.00* AbsBaso-0.00*
___ 07:08AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:20AM BLOOD Plt ___
___ 12:34PM BLOOD ___
___ 12:45AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:08AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 05:45AM BLOOD Glucose-108* UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
___:20AM BLOOD Glucose-88 UreaN-22* Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-24 AnGap-16
___ 12:45AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-100 HCO3-25 AnGap-17
___ 07:08AM BLOOD Calcium-PND Phos-PND Mg-PND
___ 05:45AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0
___ 05:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain/headache
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 250 mg 3 tablet(s) by mouth twice daily
Disp #*84 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times daily Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ y/o M p/w 6 days abd pain, +F/C, microscopic hematuria, CT
w/diverticulitis +abscess abutting bladder // eval and drainage of abscess
COMPARISON: Outside CT ___.
PROCEDURE: Ultrasound-guided drainage of a diverticular phlegmon/fluid
collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agree 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 US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, an 8 ___ Exodus catheter was
attempted to be placed within the collection, however it could not be deployed
within the small fluid collection. Therefore, an 18G ___ needle was
inserted into the collection. 0.038 ___ wire was placed through the
needle and needle was removed. This was followed by placement of a dilator
folowed by ___ Exodus catheter into the collection. The plastic
stiffener and the wire were removed, however no fluid, nor air, could be
aspirated from the catheter. The Pigtail was deployed, however the position
of the pigtail could not be confirmed via ultrasound due to the presence of
adjacent inflammatory echogenic fat. Given this finding, the patient
subsequently had a a noncontrast CT scan of the pelvis to better localize the
position of the catheter.
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 2
mg Versed and 125 mcg fentanyl throughout the total intra-service time of 27
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Small amount of fluid is seen within the pelvis, to the left and above the
bladder, correlating to the site of the small fluid collection seen on
recently performed CT scan. Extensive adjacent inflammatory fat.
Following the procedure, the location of the pigtail could not be determined
under ultrasound, and the patient's subsequently had a CT scan of the pelvis
which demonstrated little to no fluid at the site of previously seen
collection, and the pigtail catheter was positioned within the pelvis,
adjacent to where the collection was previously seen. Given these findings,
the pigtail catheter was subsequently removed.
IMPRESSION:
Attempted US-guided placement of ___ pigtail catheter into the pelvic
collection. No fluid was aspirated at the time of drain placement, and
subsequent CT scan of the pelvis demonstrated resolution of the previously
seen small collection and therefore the pigtail catheter was removed. The
patient remained stable throughout the procedure and subsequent CT scan of the
pelvis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:45 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT pelvis without contrast
INDICATION: Diverticular abscess. Evaluate position of pigtail catheter.
TECHNIQUE: Multidetector CT images of the 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: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Outside hospital CT torso ___. Ultrasound-guided
drainage ___.
FINDINGS:
Again noted is prominent thickening of the distal sigmoid colon in an area of
prominent diverticula with surrounding fat stranding compatible with acute
diverticulosis. A pigtail catheter is noted within the vicinity of a
previously noted diverticular abscess, the confines of which are difficult to
evaluate given lack of intravenous contrast, however the abscess appears to be
nearly completely resolve compared to the prior outside CT examination. It is
difficult to discern whether catheter extends into the bowel lumen.
Retained barium contrast is noted within the visualized portion of the large
bowel. The imaged portion of the abdominal aorta is normal in caliber. There
is no mesenteric, retroperitoneal, or inguinal lymphadenopathy. A few mildly
prominent left pelvic sidewall lymph nodes are noted, likely reactive. There
is no free pelvic fluid or air. Bladder, prostate and lower rectum are
grossly unremarkable.
There is no suspicious focal bone lesion.
IMPRESSION:
Left lower quadrant percutaneous pigtail catheter within a diverticular
abscess, which appears nearly completely resolved compared to the preprocedure
CT examination. The catheter is very close to the sigmoid colon and it is
uncertain whether it extends into he lumen. This can be further evaluated with
contrast injection with fluoroscopy.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 98.5
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 124.0
dbp: 80.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ was admitted to ___ on ___ following
presentation in the ED with abdominal pain which on CT done in
the ED appeared to be due to active diverticulitis with a very
small pericolonic fluid collection. He was started on IV Cipro
and IV flagyl and bowel rest with fluid resuscitation. An
attempt was made by the interventional radiology team to
percutaneously drain the abscess however this was aborted. It
was ultimately felt that the fluid collection was likely too
small and resolving sufficiently such that it does not require
additional drainage. Mr. ___ diet was gradually advanced
over the following 24 hours to regular, which he tolerated. His
abdominal pain continued to improve and was nearly completed
resolved at the time of discharge.
Mr. ___ at the time of discharge was ambulating, eating,
tolerating oral medications, and toileting himself. He was
discharged on 2 weeks of oral cipro and flagyl with scheduled
follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Pericardiocentesis (___)
Right heart catheterization (___)
Thoracic Harware removal (___)
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with h/o rheumatic heart disease (mild MS, Moderate AS),
MSSA
bacteremia ___ T4-5 epidural abscess and discitis in ___ s/p
multiple courses of antibiotic therapy, recent NSTEMI w/ normal
stress, HCV, CKD stage 3, remote IVDU, mild cognitive
impairment,
presents with fevers, worsened shortness of breath and found to
have new large pericardial effusion.
Approxiamtely 1 month ago, patient was admitted to OSH after
acute onset AMS and shortness of breath. Found there to have a
troponin elevation that was worked up with stress test, which
was
negative for ischemia. She was then admitted to ___ ___
with AMS, fevers, soft tissue mass on her thoracic spine
concerning for phlegmon. She was treated with broad spectrum
antibiotics, phlegmon was aspiration and culture did not reveal
any micro-organism. She was discharged on her chronic
suppressive
doxycycline after feeling somewhat better. She was somewhat
better but over the past 3 days prior to this presentation she
was having shortness of breath, fevers, and increased back pain.
Also developed new sternal pleuritic chest pain, which she has
not had before.
She initially presented to an ___ where she was
found to febrile and have a large pericardial effusion with
concern for possible tamponade so she was transferred to ___
ED
for further management.
In the ED,
- Initial vitals were: 99.1 ___ 18 93% 4L NC
- Exam notable for: Negative pulsus paradoxus
- Labs notable for: WBC 10.8, hgb 8.5, lactate 0.8, BNP 1752,
albumin 2.9
- Studies notable for:
- Unilateral ___ w/ no DVT
- TTE with large pericardial effusion, no e/o tamponade.
- EKG with Sinus tachycardia to 102, low volatage, no e/o
ischemia although or pericarditis although limited by
significant
aritifact.
- Patient was given: 1 L NS and 2 g cefepime (received
vancomycin at OSH)
- Cardiology was consulted: Recommended admission to CCU for
anticipation of pericardiocentesis
On arrival to the CCU, she described history c/w the above. She
noted years of intermittent joint pains and swelling, new
intermittent rashes breaking out on arms. She noted that her
mother was diagnosed with lupus.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
-MSSA Bacteremia ___ complicated by persistent T5 epidural
abscess and discitis s/p T5-T6 corpectomy, T3-T8 posterior
fusion (___) for persistent infection/vertebral body
destruction
-Remote IVDU - ___ years ago on methadone
-HCV (unclear if treated in past)
-Mild cognitive Impairment
-Opiate dependence on methadone
-CKD III (baseline Cr 0.7-1)
-History of recurrent UTI's on macrobid suppressive therapy
-Depression/Anxiety
-Decubitus ulcers
-Mitral stenosis (per echo at ___ ___
Social History:
___
Family History:
No FH of cardiac disease per patient.
Mother with h/o hemochromatosis and SLE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Reviewed in Metavision
GENERAL: Chronically ill appearing.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP up at 90 degrees.
CARDIAC: regular rate tachy, ___ SEM at base. No rub.
LUNGS: Crackles at bases. No respiratory distress
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
Back: Warm paraspinal soft tissue mass in thoracic region
SKIN: excoriations, but no clear rashes
PULSES: Distal pulses palpable and symmetric.
NEURO: AOx3. No focal lesions
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: ___ midsystolic murmur auscultated in RUSB
PULM: CTAB
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
BACK: dressing clean and dry, drain removed
NEURO: Strength ___ in bilateral upper and lower extremities.
Sensation intact to light touch bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 06:17PM BLOOD WBC-10.7* RBC-2.89* Hgb-8.5* Hct-26.9*
MCV-93 MCH-29.4 MCHC-31.6* RDW-14.3 RDWSD-48.2* Plt ___
___ 06:17PM BLOOD Neuts-71.9* Lymphs-14.1* Monos-10.5
Eos-2.1 Baso-0.5 Im ___ AbsNeut-7.66* AbsLymp-1.50
AbsMono-1.12* AbsEos-0.22 AbsBaso-0.05
___ 05:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+*
Macrocy-NORMAL Microcy-NORMAL Polychr-1+* Ovalocy-1+* Tear
Dr-OCCASIONAL
___ 06:17PM BLOOD ___ PTT-28.2 ___
___ 05:20AM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 06:17PM BLOOD Glucose-105* UreaN-15 Creat-1.2* Na-137
K-3.9 Cl-103 HCO3-23 AnGap-11
___ 06:17PM BLOOD ALT-11 AST-15 AlkPhos-78 TotBili-0.4
___ 05:20AM BLOOD ALT-13 AST-20 LD(LDH)-303* CK(CPK)-51
AlkPhos-88 TotBili-0.5 DirBili-<0.2 IndBili-0.5
___ 06:17PM BLOOD proBNP-1752*
___ 06:17PM BLOOD Albumin-2.9*
___ 05:20AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.1 Mg-1.8
Iron-16*
___ 05:20AM BLOOD calTIBC-198* Hapto-348* Ferritn-203*
TRF-152*
___ 05:20AM BLOOD RheuFac-16* ___ Titer-1:80*
CRP-161.1*
___ 05:20AM BLOOD TSH-1.3
___ 05:20AM BLOOD C3-135 C4-16
___ 06:20PM BLOOD Lactate-0.8
DISCHARGE LABS
==============
___ 08:40AM BLOOD WBC-8.8 RBC-3.00* Hgb-8.8* Hct-27.4*
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.4 RDWSD-49.4* Plt ___
___ 08:40AM BLOOD ___ PTT-31.2 ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-111* UreaN-10 Creat-1.0 Na-148*
K-3.3* Cl-109* HCO3-24 AnGap-15
___ 08:40AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
MICRO
=====
___ BCx - final no growth
___ UCx - final no growth
___ BCx - final no growth
___ pericardial fluid - gram stain negative, acid fast smear
negative. preliminary fluid culture, anaerobic culture, acid
fast culture, viral culture with no growth ***
___ pericardial fluid in blood culture bottles - no growth
___ pericardial fluid cytology - negative for malignant
cells. Rare mesothelial cells, numerous neutrophils,
lymphocytes, histiocytes, and many red blood cells.
IMAGING AND STUDIES
===================
TTE ___:
Conclusions:
Overall left ventricular systolic function is normal. The right
ventricle has normal free wall motion. There is a small (up to
0.6 cm inferolateral to the left ventricle) to moderate (up to
1.4 cm anterior to the
right ventricle) circumferential pericardial effusion. The
effusion is echo dense, c/w blood, inflammation or other
cellular elements. There are no 2D or Doppler echocardiographic
evidence of tamponade.
IMPRESSION: Small to moderate circumferential, echodense
pericardial effusion without echocardiographic evidence for
increased pericardial pressure/tamponade physiology.
Compared with the prior TTE ___ , respiratory variation
of the mitral inflow pattern is no longer appreciated.
PET ___:
1. Increased radiotracer uptake within the subcutaneous tissues
and
paraspinal musculature extending along the pedicle screws and
interconnecting rod on the right at T7 and T8, suspicious for
infection. No increased radiotracer uptake to suggest discitis
or an epidural abscess. 2. Small pericardial effusion with mild
peripheral FDG uptake; the FDG may be due pharmacokinetics of
the effusion, but could possibly reflect infection. 3. Focus of
FDG avidity along the right pericardium without a definite CT
correlate, likely a reactive epicardial lymph node. There also
nonenlarged axillary lymph nodes with low level FDG uptake, also
likely reactive in nature. 4. Multiple foci of radiotracer
uptake throughout the large bowel, which appear to correlate
with stool and are likely physiologic. 5. Smooth septal
thickening at the lung bases bilaterally, compatible with mild
fluid overload. Small bilateral pleural
effusions with loculated components in the major fissures.
CXR ___:
In comparison with the study of ___, the pericardial drain
has been
removed. There may be a small residual component of air in the
pericardium. There is decreasing opacification at the right base
consistent with mild decrease in pleural effusion, though
residual atelectasis is again seen. Left hemidiaphragm is
obscured consistent with substantial volume loss in the left
lower lobe and possible small effusion.
TTE ___:
CONCLUSION:
The left atrium is not well seen. The estimated right atrial
pressure is ___ mmHg. There is normal regional and global left
ventricular systolic function. The visually estimated left
ventricular ejection
fraction is >=55%. Normal right ventricular cavity size with
mild global free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened. The mitral valve leaflets are mildly
thickened with no
mitral valve prolapse. There is trivial mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is mild [1+] tricuspid regurgitation. The pulmonary artery
systolic pressure could not be estimated. There is a moderate
circumferential pericardial effusion. There is increased
respiratory variation in transmitral/transtricuspid inflow but
no right atrial/right ventricular diastolic collapse.
IMPRESSION: Focused study. Moderate circumferential pericardial
effusion with evidence of increased pericardial pressures but
without frank echocardiographic evidence of pericardial
tamponade. Grossly biventricular systolic function. Mild
tricuspid regurgitation.
Compared with the prior TTE ___, the findings are
similar.
TTE ___:
CONCLUSION:
The estimated right atrial pressure is ___ mmHg. There is normal
regional left ventricular systolic function. Overall left
ventricular systolic function is normal. The visually estimated
left ventricular
ejection fraction is 60-65%. Normal right ventricular cavity
size with normal free wall motion. The mitral valve leaflets
appear structurally normal. The estimated pulmonary artery
systolic pressure is
borderline elevated. There is a small to moderate
circumferential pericardial effusion. There is increased
respiratory variation in transmitral/transtricuspid inflow c/w
increased pericardial pressure/tamponade physiology.
IMPRESSION: 1) Moderately sized serous fibrinous largely
circumferential pericardial effusion. The largest extent of the
pericardial effusion is anterior to the RV/RA. There is mild
respirophasic variation
in mitral inflow velocities suggestion low pressure tamponade
physiology. RA pressure appears normal. Compared with the prior
TTE (images reviewed) of ___, the size of the pericardial
effusion
has decreased. There now is very mild respirophasic variation in
mitral inflow velcities. The cut of is 25% variation and the
measurements ranged from ___. The IVC is normal in size
suggestion low pressure tamponade physiology.
CXR ___:
1. Pericardial drain in place with decreased amount of air in
the pericardium. There is no pneumothorax.
2. Decreased bilateral pleural effusions
3. Bibasilar atelectasis
TTE ___:
CONCLUSION:
The left atrial volume index is mildly increased. The estimated
right atrial pressure is >15mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and
global left ventricular systolic function. Quantitative 3D
volumetric left ventricular ejection fraction is 61 %. Left
ventricular cardiac index is high (>4.0 L/min/m2). There is no
resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
diameter
is normal. The aortic valve leaflets (?#) are mildly thickened.
There is mild aortic valve stenosis (valve area 1.5-1.9 cm2).
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
mild pulmonary artery systolic
hypertension. There is a large circumferential pericardial
effusion. There is increased respiratory variation in
transmitral/transtricuspid inflow c/w increased pericardial
pressure/tamponade physiology.
In the presence of pulmonary artery hypertension, typical
echocardiographic findings of tamponade physiology may be
absent.
IMPRESSION: Large circumferential pericardial effusion with
signs of tamponade. Normal biventricular systolic function. Mild
aortic stenosis. Mild mitral and tricuspid regurgitation. Mild
pulmonary hypertension. Compared with the prior TTE ___,
the pericardial effusion is now larger.
CXR ___:
Pericardial drain in place with small quantity of anticipated
air in the
pericardium. Decreasing pleural effusions and opacities
suggesting
atelectasis the lung bases.
Echo ___: Overall left ventricular systolic function is
normal. The right ventricle has low normal free wall motion.
The pulmonary artery systolic pressure could not be estimated.
There is a large circumferential
pericardial effusion predominantly located adjacent to the right
ventricle. There is right atrial systolic
collapse c/w early tamponade physiology. There is mild TV/MV
inflow respiratory variation. The pericardial thickness is
normal.
IMPRESSION: Large circumferential/anterior pericardial effusion
with early signs of echocardiographic tamponade.
Compared with the prior TTE (images reviewed) of ___ ,
the pericardial effusion is larger(was present but small on
prior echo) and there are now early signs of tamponade
physiology.
Unilateral lower extremity veins right ___: No evidence of
deep venous thrombosis in the right lower extremity veins.
EKG ___: EKG with Sinus tachycardia to 102, low volatage, no
e/o
ischemia although or pericarditis although limited by
significant
aritifact.
TTE ___: EF 65%, Moderate AS, mild MS from rheumatic heart
disease.
STRESS TEST: ___: Reportedly negative at CHA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO QAM Anxiety
4. Doxepin HCl 10 mg PO HS
5. Levothyroxine Sodium 112 mcg PO DAILY
6. DULoxetine 40 mg PO DAILY
7. Methadone 89 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Senna 17.2 mg PO QHS
10. ClonazePAM 1.5 mg PO LUNCH anxiety
11. Ditropan XL (oxybutynin chloride) 10 mg oral BID
12. Docusate Sodium 100 mg PO BID
13. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Nafcillin 2 g IV Q4H
RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 grams IV every
4 hours Disp #*180 Intravenous Bag Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth once
daily Disp #*30 Tablet Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. ClonazePAM 1 mg PO QAM Anxiety
6. ClonazePAM 1.5 mg PO LUNCH anxiety
7. Ditropan XL (oxybutynin chloride) 10 mg oral BID
8. Doxepin HCl 10 mg PO HS
9. DULoxetine 40 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Methadone 89 mg PO DAILY
Consider prescribing naloxone at discharge
12. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pericardial effusion with tamponade
Acute Kidney Injury
Secondary diagnoses:
Normocytic anemia
CKD III
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ woman with leg swelling// ?R 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.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: Chest radiograph, semi-upright AP portable.
INDICATION: Enlarged pericardial effusions status post pericardiocentesis.
COMPARISON: Prior day.
FINDINGS:
New pericardial drain projects to the left of midline. Associated pericardial
air is found. Cardiac shadow is somewhat reduced in size, although it is
difficult to the separated change in the size of the cardiac shadow from
coinciding reduction in atelectasis at the lung bases and in bilateral pleural
effusions. There is no pneumo thorax.
IMPRESSION:
Pericardial drain in place with small quantity of anticipated air in the
pericardium. Decreasing pleural effusions and opacities suggesting
atelectasis the lung bases.
Radiology Report
EXAMINATION: Portable AP chest
INDICATION: ___ year old woman with large pericardial effusion s/p
pericardiocentesis.// r/o pneumothorax
TECHNIQUE: Portable AP chest
COMPARISON: Portable AP chest from ___
FINDINGS:
In comparison the previous film, there is little overall change. There is no
evidence of pneumothorax. Pericardial drain is unchanged in position. There
is a small amount of air in the pericardium which is decreased in size from
the prior film. There continues to be bibasilar atelectasis. There are
bilateral pleural effusions that have decreased from the prior exam. Hardware
is unchanged.
IMPRESSION:
1. Pericardial drain in place with decreased amount of air in the pericardium.
There is no pneumothorax.
2. Decreased bilateral pleural effusions
3. Bibasilar atelectasis
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with h/o rheumatic heart disease (mild MS, Moderate AS),
MSSAbacteremia ___ T4-5 epidural abscess and discitis in ___ s/pmultiple
courses of antibiotic therapy, recent NSTEMI w/ normalstress, HCV, CKD stage
3, remote IVDU, mild cognitive impairment,presents with fevers, worsened
shortness of breath and found tohave new large pericardial effusion, now s/p
pericardiocentesis.// cardiopulmonary reason for shortness of breath?
reaccumulation of pericardial evidence?
IMPRESSION:
In comparison with the study of ___, the pericardial drain has been
removed. There may be a small residual component of air in the pericardium.
There is decreasing opacification at the right base consistent with mild
decrease in pleural effusion, though residual atelectasis is again seen. Left
hemidiaphragm is obscured consistent with substantial volume loss in the left
lower lobe and possible small effusion.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST
INDICATION: ___ year old woman s/p T5-T6 corpectomy and T3-T8 posterior fusion
who presented with pericardial effusion requiring pericardiocentesis. Evidence
of spine hardware infection seen on ___ PET scan.// evidence of hardware
infection? evidence of hardware infection?
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 4.0 s, 31.9 cm; CTDIvol = 27.2 mGy (Body) DLP = 866.4
mGy-cm.
Total DLP (Body) = 866 mGy-cm.
COMPARISON: MR ___ dated ___. Prior CT T spine dated ___
FINDINGS:
Exaggerated thoracic kyphosis with spondylosis is persistent otherwise
alignment is unchanged. There are unchanged multilevel degenerative changes
in the lower cervical and upper thoracic spine. The anterior fusion involves
T5-T6 level with biomechanical device in place. The posterior fixation rods
spanning with by medical device placement at T5-T6. Fusion involves T2-T8.
The anterior fusion of T5-T6. At the vertebral body of T5 there is the
previously described lucency around the left lateral margin of the
intervertebral biomechanical device, (series 2, image 44), is no longer
demonstrated. However, there is streak artifact from hardware and evaluation
of the spinal canal is limited.
Again demonstrated is the right T3 pedicular screw at the lateral margin of
the T3 vertebral body with less than a mm of perihardware lucency (series 602
image 34). There is no evidence of periarticular fracture.
There is no evidence of spinal canal or neural foraminal stenosis. There is no
prevertebral soft tissue swelling. No evidence of drainable fluid collection
within the paraspinal musculature or visualized spinal canal. Re-demonstrated
are small bilateral pleural effusions, left greater than right. There mild
interval improvement of loculated effusion along the right oblique fissure.
However there still is layering of pleural fluid along the oblique fissures.
There are bibasilar ground-glass opacification likely representative of
atelectasis.
IMPRESSION:
1. No evidence of hardware complication within the limitations of streak
artifact.
2. Bilateral small pleural effusions left greater than right with bibasilar
atelectasis.
Radiology Report
EXAMINATION: THORACIC SINGLE VIEW IN OR
INDICATION: POST. RMVL T2-8 HARDWARE
TECHNIQUE: Frontal view radiograph of the thoracic spine.
COMPARISON: CT Thoracic Spine ___.
FINDINGS:
There has been interval removal of the posterior spinal fixation hardware in
the thoracic spine. The expandable vertebral body cage in the midthoracic
spine is still present.
The endotracheal tube terminates 3.5 cm above the carina. An tubular
structure which projects of the cervical and thoracic spine may represent a
surgical drain.
There is cardiomegaly. Hazy opacities in the partially visualized lower lungs
may represent pleural effusions.
IMPRESSION:
Interval removal of the posterior thoracic spinal fixation hardware.
Radiology Report
INDICATION: ___ year old woman with PICC// Pt had a L PICC,44cm ___ ___
Contact name: ___: ___
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided PICC line projects to the cavoatrial junction. Lungs are low
volume with bibasilar atelectasis. Pulmonary edema is slightly improved.
Cardiomediastinal silhouette is stable. Small bilateral effusions are
unchanged. No pneumothorax is seen. The spinal hardware has been removed in
the interim.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, PERICARDIAL EFFUSION, Transfer
Diagnosed with Pericardial effusion (noninflammatory), Dyspnea, unspecified
temperature: 99.1
heartrate: 106.0
resprate: 18.0
o2sat: 93.0
sbp: 92.0
dbp: 66.0
level of pain: 3
level of acuity: 2.0 | ___ with h/o rheumatic heart disease (mild MS, Moderate AS),
MSSA bacteremia ___ T4-5 epidural abscess and discitis in ___
s/p multiple courses of antibiotic therapy, recent NSTEMI w/
normal stress, HCV, CKD stage 3, remote IVDU, mild cognitive
impairment, presents with fevers, worsened shortness of breath
and found to have new large pericardial effusion, now s/p
pericardiocentesis. She was then transferred to the medicine
service for ongoing management spinal soft tissue infection. Per
ID and Ortho recommendations, her spinal hardware was removed
for source control and she was started on a 6 week course of
Nafcillin.
#CORONARIES: Negative stress at CHA
#PUMP: EF 65%, Moderate AS, mild MS from rheumatic heart
disease.
#RHYTHM: Sinus tachycardia
ACUTE ISSUES:
=============
# Pericardial effusion with tamponade
New effusion with symptoms of pleuritic CP. S/p
pericardiocentesis ___. Unclear etiology. Concern for ___
syndrome. Differential includes infectious in the setting of
chornic spinal infetion, autoimmune in the setting of joint
pain/rashes, malignancy all of which are less likely. Cytology
was negative for malignancy. Autoimmune studies were remarkable
for ___ pos, RF 16 Titer 1:80, CRP 161, normal C3, C4.
Rheumatology was consulted and did not suspect a rheumatologic
etiology for her pericardial effusion given the data above.
Patient also has signs suggestive of pericarditis (ecg changes,
pleuritic chest pain on admission). Fluid studies including gram
stain and cultures have been negative to date. Patient was begun
on Colcichine 0.6 mg BID and naproxen to treat pericarditis.
Both drugs were then stopped after patient was clinically stable
due to concerns of kidney injury.
# Spinal Infection
Fevers/leukocytosis on admission likely due to spinal infection
given history of chronic spine infection on suppressive
doxycycline and recent thoracic soft tissue phlegmon. A PET scan
done on ___ showed increased radiotracer uptake within the
subcutaneous tissues and paraspinal musculature extending along
the pedicle screws and interconnecting rod on the right at T7
and T8, suspicious for infection. A CT scan on ___ showed no
evidence of hardware complication within the limitations of
streak artifact. ID and orthopedic surgery were consulted and
recommended removal of spinal hardware. S/p surgery ___.
Discharged on 6 weeks of IV naficillin 2g Q4H. Pt will require
weekly LFT and CBC check. After completion of nafcillin, pt will
not be restarted on suppressive doxycycline.
# ___ on CKD, resolved: Cr to max of 1.5 during admission
(baseline 1.0). Likely due to pre-renal hypovolemic etiology
with possible contribution from NSAIDs, resolved with IVF. No
evidence of ATN/AIN. Colchicine/naproxen stopped prior to
discharge as above. Cr 1.0 upon discharge.
# Anemia: Acute on chronic normocytic anemia. Anemia of chronic
inflammation given increased ferritin, low TIBC, low
transferrin. Also iron deficiency present given tsat 8%. Treated
with IV iron.
# Recent NSTEMI: Occurred in setting of evluation for acute
onset dyspnea at ___ ealier in ___ stress per patient
at ___. Not on statin due to low ASCVD risk per HCA notes.
Continued ASA.
# H/o Rheumatic heart disease, moderate AS, Mild MS: Murmur
notable on exam. Possible etiology of pulmonary edema. Did not
require diuresis following pericardiocentesis.
CHRONIC ISSUES:
===============
# CKD III: ___ resolved as above.
#h/o IVDU: continued methadone 89 mg QD
# Overactive bladder: oxybutynin ER not on formulary, oxybutynin
5 mg QID while in hospital.
# Pruritus: Pt with a history of pruritus. Continued home
doxepin.
# Anxiety/Depression: Continued outpt duloxetine 40 mg QD.
Continue clonazepam 1 mg qAM and 1.5 mg QPM.
# Hypothyroidism: Continue home levothyroxine 112 mcg QD
TRANSITIONAL ISSUES:
==============
[] New diarrhea on ___. Please follow up to r/o C. Diff.
Stool sample was taken on day of discharge.
[] Consider iron supplementation as outpatient
[] Weekly LFT and CBC due to Naficillin use
[] Consider repeat CRP at follow-up to ensure down-trending.
[] Continue naficllin 2g Q24 for 6 week course (last day ___
[] Check BMP at next PCP appointment to monitor Na (Na 148 on
discharge) and potassium (3.3 on discharge)
#CODE: Full
#CONTACT/HCP: Proxy name: ___ (husband) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Post partum hemorrhage
Major Surgical or Invasive Procedure:
Uterine artery embolization
D&C for retained products of conception
History of Present Illness:
___ year old G1P1 POD10 from cesarean section for failure to
progress, complicated by post partum hemorrhage, requiring D&C
and Bakri Balloon placement x 24 hours and multiple blood
products, presents to ED by ambulance after developing heavy
vaginal bleeding this evening while breast-feeding. She reports
feeling vaginal bleeding soaking through her pants, followed by
a
large gush. She was reportedly found diaphoretic and hypotensive
to the ___ systolic by EMS, and was transferred to ___ ED. She
denies loss of consciousness, although she has felt dizzy with
sitting up. No chest pain or shortness of breath.
Of note, her cesarean section was performed on ___, and
notable for manual delivery of the placenta, which was reported
to be intact. The uterus was then wiped with a laparotomy pad,
with "no placental fragments remaining." The EBL for the case
was
600cc. She then subsequently had heavy vaginal bleeding with
concern for atony. A dilation and evacuation was performed,
followed by sharp curettage with a banjo curette. A Bakri
balloon
was placed and kept in place x 24 hours. Her total EBL was
2400cc. She received a total of 6u pRBC and 2 units FFP
transfusion while at ___, and was discharged home on
post-operative day 5. Her hematocrit on discharge was 28.
Past Medical History:
___: Denies
PSH: Cesarean section, tonsillectomy
OBHx: G1P1, LTCS as above on ___ of 8 lb, 15 Oz baby at
41+6
weeks EGA, also complicated by chorioamnionitis and postpartum
hemorrhage as above
GYNHx: Denies uterine procedures. Hx of infertility with
multiple
egg transfers.
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
T 98.5 HR 77 BP 117/76 RR 18 O2 sat 97% RA
Gen: NAD
CV: RRR
Abd: soft, non-tender. Fundus palpated at umbilicus, firm.
Bedside TAUS: vascularized products vs. clot ~3.8cm in size
visualized in lower uterine segment
Bimanual exam: cervix dilated ~2-3cm, with removal of a plum
sized clot from lower uterine segment.
Pertinent Results:
___ pelvic MRI
6.5 cm uterine mass composed of innumerable early vessels with
early arterial enhancement and early venous drainage, indicative
of an arteriovenous malformation. This is centered within the
left lower uterine myometrium, with intramural vascular
communication circumferentially, and a large component extending
into the endometrial cavity. Arterial supply appears to be
predominantly via the left ovarian artery, and venous drainage
via the left internal iliac vein and possibly the left gonadal
vein.
___ PUS
1. Echogenic material measuring 6.1 cm within the endometrial
cavity
demonstrating a small amount of venous flow representing
retained products of conception. Fluid is also demonstrated
within the cavity.
2. Large region of abnormal vascularity in the left lateral
myometrium with peak systolic velocity of 117 cm/sec and
end-diastolic velocity of 74 cm/sec suggestive of residual AV
connection.
___ abd CT
IMPRESSION:
1. The ovarian veins appear patent. There is no evidence of
thrombophlebitis.
2. Enlarged uterus as detailed above with retained fluid and
multiple locules of gas. Gas is presumably from prior
instrumentation two days ago, however it is difficult to exclude
gas-forming bacteria within blood products, in the setting of
fever.
3. No evidence of abscess or other drainable fluid collection.
4. Small foci of nondependent gas within the bladder are likely
related to recent Foley catheter; correlate with catheter
history.
___ renal US
IMPRESSION:
Mild left hydronephrosis and mild left proximal hydroureter. The
mid and
distal ureter are not well seen on this study. No stone or mass
identified. Bladder not well evaluated. Consider urological
consultation.
___ 10:20 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:31 pm BLOOD CULTURE Source: Venipuncture 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:17 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. <10,000 organisms/ml.
___ 07:20AM BLOOD WBC-6.6 RBC-2.98* Hgb-8.9* Hct-26.2*
MCV-88 MCH-29.8 MCHC-34.0 RDW-14.6 Plt ___
___ 04:34AM BLOOD WBC-7.9 RBC-2.77* Hgb-8.1* Hct-24.0*
MCV-87 MCH-29.2 MCHC-33.8 RDW-14.4 Plt ___
___ 01:15PM BLOOD WBC-7.7 RBC-2.58* Hgb-7.5* Hct-22.6*
MCV-88 MCH-29.0 MCHC-33.1 RDW-14.6 Plt ___
___ 07:45AM BLOOD WBC-7.2 RBC-2.43* Hgb-7.2* Hct-21.6*
MCV-89 MCH-29.8 MCHC-33.5 RDW-14.7 Plt ___
___ 07:18AM BLOOD WBC-11.2* RBC-2.61* Hgb-7.6* Hct-23.1*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.6 Plt ___
___ 07:00AM BLOOD WBC-15.1* RBC-2.76* Hgb-8.2* Hct-24.5*
MCV-89 MCH-29.5 MCHC-33.3 RDW-14.8 Plt ___
___ 11:02AM BLOOD WBC-13.6*# RBC-3.26* Hgb-10.2* Hct-28.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-14.9 Plt ___
___ 03:00AM BLOOD WBC-7.3 RBC-3.04* Hgb-9.1* Hct-26.8*
MCV-88 MCH-29.9 MCHC-34.0 RDW-14.8 Plt ___
___ 06:56PM BLOOD WBC-11.0# RBC-3.77* Hgb-11.5* Hct-33.8*
MCV-90 MCH-30.5 MCHC-34.1 RDW-14.6 Plt ___
___ 07:45AM BLOOD Neuts-68.0 ___ Monos-5.9 Eos-2.5
Baso-0.7
___ 07:18AM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.4
Eos-1.4 Baso-0.3
___ 06:56PM BLOOD Neuts-77.8* Lymphs-15.9* Monos-4.7
Eos-1.3 Baso-0.3
___ 07:20AM BLOOD Plt ___
___ 04:34AM BLOOD Plt ___
___ 11:02AM BLOOD ___ PTT-26.8 ___
___ 03:00AM BLOOD Plt ___
___ 03:00AM BLOOD ___ PTT-25.8 ___
___ 12:27AM BLOOD Plt ___
___ 07:08PM BLOOD ___ PTT-23.9* ___
___ 06:56PM BLOOD Plt ___
___ 11:02AM BLOOD ___ 03:00AM BLOOD ___ 07:35AM BLOOD Creat-1.8*
___ 07:20AM BLOOD UreaN-8 Creat-1.7*
___ 09:01AM BLOOD Glucose-96 UreaN-9 Creat-1.6* Na-141
K-4.9 Cl-108 HCO3-26 AnGap-12
___ 04:34AM BLOOD Creat-1.6*
___ 01:15PM BLOOD Creat-1.3*
___ 11:02AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-138 K-4.1
Cl-102 HCO3-27 AnGap-13
___ 03:00AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-140 K-3.9
Cl-108 HCO3-24 AnGap-12
___ 06:56PM BLOOD Glucose-99 UreaN-12 Creat-1.0 Na-138
K-4.7 Cl-104 HCO3-22 AnGap-17
___ 11:02AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
___ 06:56PM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
___ 01:15PM BLOOD ALT-12 AST-16
___ 11:02AM BLOOD HCG-30
___ 03:00AM BLOOD HCG-32
___ 10:02AM URINE Hours-RANDOM Creat-68 Na-161 K-18 Cl-124
___ 07:17PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 06:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 08:40PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:03PM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-0
Radiology Report
EXAMINATION: MRI of the pelvis with and without contrast
INDICATION: ___ year old woman with delayed secondary postpartum hemorrhage.
// Please evaluate for any evidence of an arteriovenous malformation
TECHNIQUE: Multiplanar MRI of the pelvis is obtained at 1.5 Tesla both pre
and post administration of 15 mL of MultiHance.
COMPARISON: None
FINDINGS:
An enlarged uterus is identified in this recently postpartum patient with the
fundus extending to the level of the umbilicus. There is gas and hemorrhagic
fluid is seen within the endometrial canal, extending to the endocervical
canal in the upper vagina. Thinning of the anterior lower uterine segment is
noted with associated susceptibility artifact, edema and enhancement
transversely along the lower abdominal wall, consistent with recent cesarean
section.
There is a masslike lesion composed innumerable serpentine vessels centered
within the left lower uterine wall extending into the endometrial cavity. This
has approximate total ___ of 5 x 5.5 x 6.5 cm. On pre contrast imaging,
there are both areas of T2 hyperintensity, particularly in extending into the
endometrial cavity, as well as areas of T2 hypointense flow voids. This area
is relatively homogeneously intermediate in signal on T1 weighted sequences
and low in signal on diffusion-weighted sequences. After administration of
contrast, there is brisk enhancement of innumerable serpiginous vessels
thought to represent a combination of arteries and veins given the early,
asymmetric contrast opacification of the left internal iliac vein (1251S: 32).
Contrast opacification of an asymmetrically enlarged left gonadal vein is also
earlier than expected, likely on the basis of early drainage from this the
vascular nidus (12:54). While the majority of the vessels are confined to this
masslike nidus, there is communication with a myometrial of vessels extending
circumferentially around the uterus to the contralateral side (1250:9).
There is a trace amount of free pelvic fluid. The ovaries are normal in
appearance. Osseous structures are unremarkable.
IMPRESSION:
6.5 cm uterine mass composed of innumerable early vessels with early arterial
enhancement and early venous drainage, indicative of an arteriovenous
malformation. This is centered within the left lower uterine myometrium, with
intramural vascular communication circumferentially, and a large component
extending into the endometrial cavity. Arterial supply appears to be
predominantly via the left ovarian artery, and venous drainage via the left
internal iliac vein and possibly the left gonadal vein.
NOTIFICATION: Interpretation was discussed with via phone by Dr ___
with Dr ___ at approximately 4:30pm on ___. Plan is for treatment
with endovascular embolization.
Radiology Report
INDICATION: ___ female with major postpartum hemorrhage status post
c-section and D&C with uterine AV fistula demonstrated on pelvic MRI.
COMPARISON: MRI of the pelvis from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr. ___
___ (radiology resident, and Drs. ___ (interventional
radiology attendings) performed the procedure. The attendings, Drs. ___
___ were present and supervising throughout the procedure. Drs.
___, attending radiologists, personally supervised the
trainee during the key components of the procedure and reviewed and agreed
with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 3 hours 10 minutes during which the patient's hemodynamic parameters
were continuously monitored by an independent trained radiology nurse. 1%
lidocaine was injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: Fentanyl, midazolam, 200 mcg nitroglycerin, 2 g cefazolin.
CONTRAST: 297 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 40 minutes, 1156 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Left internal iliac arteriogram with cone beam CT.
3. Left uterine arteriogram.
4. Embolization of the left uterine artery to stasis utilizing cyanoacrylate
glue/lipiodol mixture.
5. Right uterine arteriogram.
6. Aortogram extending to the superficial femoral arteries.
7. Selective left ovarian arteriogram.
PROCEDURE DETAILS:
Following a 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. Right groin was
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a 21 gauge micropuncture needle at the level of the mid
femoral head. A Nitinol wire was advanced into the aorta. A small skin
incision was made over the needle and the needle was exchanged for a
micropuncture sheath. The inner stiffener and wire were removed and ___
wire was advanced into the aorta. The micropuncture sheath was then exchanged
for a 5 ___ sheath which was attached to a continuous heparinized saline
side arm flush.
An Omni flush catheter was advanced over the wire and the ___ wire was
exchanged for a Glidewire. The Glidewire was used to select the left external
iliac artery and the Omniflush catheter was exchanged for a pudendal catheter.
The pudendal catheter was used to cannulate the left internal iliac artery. A
left internal iliac arteriogram was performed.
Rotational cone-beam CT angiography was performed to help delineate the
anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered
images of the arterial anatomy required post-processing on an independent
workstation under direct physician ___ (attendings Dr. ___
Dr. ___. These images were used in the interpretation, decision making
for intervention and reporting of this procedure.
A left uterine arteriogram was performed. Using the arteriogram as a road map
a pre-loaded high-flow Renegade catheter and Transcend wire were advanced
distally into the uterine artery. Initially, some spasm was noted and 200 mcg
of nitroglycerin was administered. Following resolution of spasm, the pudendal
catheter was advanced slightly to decrease arterial inflow. Embolization of
the arteriovenous fistula was performed with cyanoacrylate/lipiodol mixture to
stasis. The microcatheter was retracted and a more proximal injection in the
left uterine artery demonstrated recruitment of several additional branches
supplying the arteriovenous fistula. Embolization to stasis was then performed
at the more proximal left uterine artery. Repeat left internal iliac
arteriogram demonstrates cessation of flow into the left uterine artery and no
flow towards the arteriovenous fistula.
The microcatheter was then removed and the pudendal catheter was used to
engage the right uterine artery. A right uterine arteriogram was performed.
The Glidewire was then used to unform the pudendal catheter and the pudendal
catheter was exchanged for the Omni Flush catheter.
An aortogram was performed just below the level of the renal arteries to
evaluate the ovarian arteries.
The Omni Flush catheter was then exchanged for ___ catheter. The
___ catheter was used to selectively cannulate the ostium of the left
ovarian artery. The Renegade Hi Flow microcatheter and microwire were used to
advance slightly more distal into the left ovarian artery. A selective left
ovarian arteriogram was performed.
The catheters and wires were then removed and the sheath was removed. Manual
pressure was held until hemostasis was achieved. Sterile dressings were
applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Left uterine artery supplying a large arteriovenous fistula with drainage
into the internal iliac and left gonadal veins.
2. Embolization of the arteriovenous fistula utilizing cyanoacrylate
glue/lipiodol mixture with embolization performed to stasis. The pudendal
catheter was advanced into the left uterine artery during embolization to
decrease arterial inflow and prevent non-target embolization through the
fistula.
3. Repeat contrast injection from the proximal left uterine artery following
embolization demonstrated recruitment of at least two additional branches
supplying the arteriovenous fistula from the more proximal left uterine
artery.
4. Embolization of the left uterine artery to stasis back towards its more
proximal segment.
5. Repeat left internal iliac arteriogram demonstrates cessation of flow into
left uterine artery and arteriovenous fistula. Flow is preserved in the
remaining branches of the internal iliac artery.
6. Right uterine arteriogram demonstrates hypervascularity related to
postpartum state. No supply to arteriovenous fistula was noted.
7. Aortogram demonstrates hypertrophy of bilateral ovarian arteries, as
expected given immediate postpartum state.
8. Selective left ovarian arteriogram demonstrates no supply to the
arteriovenous fistula.
IMPRESSION:
Successful cyanoacrylate/lipiodol embolization of the left uterine artery and
arteriovenous fistula to stasis.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with heavy vaginal bleeding s/p embolization
now with more bleeding POD#1 from embolization // eval for any other source
of bleeding, rpoc
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach. The patient declined transvaginal sonography.
COMPARISON: MRI dated ___
FINDINGS:
The uterus is anteverted and retroflexed and measures 15.3 x 7.0 x 10.0 cm.
Echogenic material and fluid is demonstrated within the endometrial cavity.
The echogenic material measures 6.1 x 3.7 cm. A small amount of venous flow is
demonstrated within the echogenic material.
The left lateral myometrium demonstrates a large region with abnormal
vascularity. This region appears hypervascular with peak systolic velocity of
117 cm/sec and end-diastolic velocity of 74 cm/sec. The ovaries were not
imaged. There is no free fluid.
IMPRESSION:
1. Echogenic material measuring 6.1 cm within the endometrial cavity
demonstrating a small amount of venous flow representing retained products of
conception. Fluid is also demonstrated within the cavity.
2. Large region of abnormal vascularity in the left lateral myometrium with
peak systolic velocity of 117 cm/sec and end-diastolic velocity of 74 cm/sec
suggestive of residual AV connection.
NOTIFICATION: The findings were discussed by ___ with Dr. ___
___ on the telephone on ___ at 10:11 AM, 5 minutes after discovery of
the findings.
Radiology Report
INDICATION: ___ woman s/p LTCS on ___ c/b hemorrhage, readmitted with
vaginal bleeding and imaging c/f AVM s/p embolization ___ and US-guided D C
for rPOC ___ now with fever to 101.5 // r/o intra-abdominal infection,
pelvic thrombophlebitis
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis first without contrast utilizing low-dose technique and then after
administration of Omnipaque IV contrast and scanning in the venous phase.
Multiplanar axial, coronal, sagittal and maximal intensity projection coronal
images were generated.
DOSE: Total body DLP: 424 mGy-cm
COMPARISON: MR ___ ___
FINDINGS:
LOWER CHEST: The included lung bases are clear. The heart is not enlarged and
there is no pericardial effusion.
CT ABDOMEN WITH CONTRAST:
HEPATOBILIARY: The liver enhances normally without focal lesions. There is no
intra or extrahepatic biliary duct dilation. The gallbladder is normal without
stones or wall thickening. The portal vein is patent.
PANCREAS: The pancreas has normal attenuation without focal lesions, duct
dilation or peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation without focal lesions.
ADRENALS: Bilateral adrenal glands are normal in size and shape.
URINARY: The kidneys excrete contrast promptly and symmetrically and are
without hydronephrosis, mass or perinephric abnormality. 3 mm hypodense
rounded focus in the interpolar region of the right kidney is too small to
characterize but is most likely a simple cyst.
GASTROINTESTINAL: The stomach, small and large bowel are normal in caliber
without wall thickening or obstruction.
RETROPERITONEUM: There is a 1.3 cm left retroperitoneal lymph node (06:42).
CT PELVIS WITH CONTRAST: The uterus remains enlarged measuring 13.7 x 7.6 x
10.1 cm. The endometrium is distended to approximately 22 mm containing fluid
and multiple locules of gas. A large amount of amorphous hyperdense material
along the left inferior aspect of the uterus and cervix is compatible with
embolic material (cyanoacrylate/lipiodol).
A few loculated gas in the urinary bladder are noted non dependently. There is
small amount of free fluid in the pelvis
CTV ABDOMEN AND PELVIS: Bilateral gonadal veins appear patent. The abdominal
aorta and iliac arteries are normal in caliber.
BONES AND SOFT TISSUES: There are no worrisome blastic or lytic lesions. The
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The ovarian veins appear patent. There is no evidence of thrombophlebitis.
2. Enlarged uterus as detailed above with retained fluid and multiple locules
of gas. Gas is presumably from prior instrumentation two days ago, however it
is difficult to exclude gas-forming bacteria within blood products, in the
setting of fever.
3. No evidence of abscess or other drainable fluid collection.
4. Small foci of nondependent gas within the bladder are likely related to
recent Foley catheter; correlate with catheter history.
NOTIFICATION: The findings were telephoned to Dr. ___ By ___ at
21:55, ___, 5 min after discovery.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with worsening creatinine and mild left flank
pain // please eval for any souurce of infection, worsening creatinine
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
RIGHT: The right kidney measures 10.6 cm. There is no hydronephrosis, stones,
or masses. Normal cortical echogenicity and corticomedullary differentiation.
LEFT: The left kidney measures 11.1 cm. There is mild left hydronephrosis
and mild left proximal hydroureter. The mid and distal ureter are not well
seen. No stones or masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation.
The bladder is only minimally distended and can not be fully assessed on the
current study.
IMPRESSION:
Mild left hydronephrosis and mild left proximal hydroureter. The mid and
distal ureter are not well seen on this study. No stone or mass identified.
Bladder not well evaluated. Consider urological consultation.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
at 1223 pm on ___ by phone at time of discovery.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by UNKNOWN
Chief complaint: Vaginal bleeding
Diagnosed with DELAY P/PART HEM-POSTPAR
temperature: 99.8
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 107.0
dbp: 63.0
level of pain: 1
level of acuity: 2.0 | Ms. ___ is ___ year old s/p LTCS on ___ at ___
___ with postpartum hemorrhage s/p D&C and Bakri
balloon placement who presented with vaginal bleeding at home
and concern for secondary postpartum hemorrhage. She was
hemodynamically stable on admission with no active bleeding.
There was initial concern for abnormal placentation vs. vascular
malformation and Maternal Fetal Medicine was consulted. A
bedside US revealed a vascularized intrauterine mass and a MRI
was done ___ for further characterization. MRI findings
were consistent with arterial venouse malformation.
Interventional Radiology was consulted and she underwent
embolization on ___. Please see procedure note for details.
She continued to have bleeding post embolization and an pelvic
ultrasound was consistent with retained products of conception.
She underwent an US guided D&C on ___. Please see operative
note for details. She received uterotonics and had improved
bleeding. She was transfused one unit packed RBC ___ for
symptomatic anemia with appropriate hematocrit and symptomatic
response. She developed a post-procedural fever to 101.8F
concerning for endometritis. CT did not show abdominal
collections or evidence of thrombophlebitis. Infectious disease
was consulted and she was treated initially with IV
ampicillin/gentamycin/clindamycin. She was subsequently noted to
have ATN possibly secondary to drug toxicity and switched to
Unasyn on ___. Her blood cultures were negative and she was
treated for yeast in her urine culture. She was afebrile for
over 48 hours and was discharged on oral Augmentin.
Urology was consulted given ___ with concerns of embolization
material in the left ureteral vessels. Renal US showed Mild left
hydronephrosis and mild left proximal hydroureter. Her
creatinine was trended. Ureteral stenting was deferred pending
renal functional testing for obstruction that was scheduled as
an outpatient. She was discharged home in stable condition on
___ with antibiotics and close outpatient follow-up
scheduled and precautions provided. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / lisinopril / clavulanic acid / atenolol
Attending: ___.
Chief Complaint:
chills, malodorous urine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with PMHx of paraplegia with neurogenic
bladder and frequent UTIs, recently admitted to ___ on
___ for Pseudomonas UTI treated with cefepime, who
presenting with concern of UTI for 1 day. He endorses feeling
hot, chills, and malodorous urine. Urine was murky in color. He
was given 7 days of cefepime, but wonders if he needed 10 days
instead. Has some nausea, no vomiting. Unable to feel below T4
at baseline and therefore not aware if burning while peeing.
Denies back pain, chest pain, shortness of breath, headache,
dizziness, diarrhea.
He recently completed 5 days of Cefepime in ___, given
through a PICC linem which was subsequently removed. He uses a
condom catheter and bag for urination. He lives alone at home
without any other assistant.
In the ED:
- VS were T 99.4 HR 88 BP 144/67 RR 20 SaO2 100%
- On exam, he had no CVA tenderness, AKA of right leg, right leg
- Labs were notable for WBC 11.1 with PMNs 71.7%, phos 2.5,
lactate 1.7, UA with large leuk, neg nitrite, 46 WBC, 1 epi
- Blood and urine cultures were taken
- He was given 2g cefepime, 5mg oxycodone, 10mg baclofen, 25mg
amitryptyline
- He was admitted for complicated UTI
On the floor, he feels well. Otherwise ROS is negative.
Past Medical History:
Paraplegia due to fall down shaft in ___
Recurrent UTIs
Osteomyelitis s/p left AKA ___
Prostate cancer s/p surgical resection in ___, no
chemoradiation
Phantom limb pain
Corneal dystrophy, anterior
s/p cataract surgery on R eye
Social History:
___
Family History:
Pt unaware of significant family history.
Physical Exam:
EXAM ON ADMISSION:
======================
Vitals: T 98.1 BP 148/68 HR 84 RR 18 SaO2 94% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, + pectus
excavatum
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, right leg with
msucular atrophy, left leg AKA
NEURO: CN II-XII intact, absent sensation below navel, paralysis
of ___ ___, ___ strength UEs
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE:
======================
Vitals: 98.0 (98.7) 136/74 (136-156/64-78) 85 (72-86) 20
(___) 97% RA (97-100% RA)
GENERAL: NAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, + pectus
excavatum
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, right leg with
msucular atrophy, left leg AKA
NEURO: grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
===================
___ 07:20PM BLOOD WBC-11.1* RBC-4.99 Hgb-14.5 Hct-42.1
MCV-84 MCH-29.1 MCHC-34.5 RDW-14.4 Plt ___
___ 07:20PM BLOOD Neuts-71.7* ___ Monos-6.4 Eos-1.7
Baso-0.5
___ 07:20PM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-134
K-4.3 Cl-97 HCO3-23 AnGap-18
___ 07:20PM BLOOD Calcium-9.0 Phos-2.5* Mg-2.3
___ 07:35PM BLOOD Lactate-1.7
___ 03:40PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:40PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 03:40PM URINE RBC-8* WBC-46* Bacteri-FEW Yeast-NONE
Epi-1
___ 03:40PM URINE AmorphX-RARE
LABS ON DISCHARGE:
===================
___ 07:41AM BLOOD WBC-9.7 RBC-5.02 Hgb-14.5 Hct-43.1 MCV-86
MCH-28.8 MCHC-33.6 RDW-14.5 Plt ___
___ 07:41AM BLOOD Glucose-67* UreaN-11 Creat-0.5 Na-137
K-4.0 Cl-100 HCO3-20* AnGap-21*
___ 07:41AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
MICROBIOLOGY:
===================
___ 3:40 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 7:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:59 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES:
===================
___ LINE REPLACEMENTStudy Date of ___ 11:02 AM
IMPRESSION:
Successful placement of a 47 cm left arm approach single lumen
PICC with tip in the lower SVC. The line is ready to use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO QHS
2. Amlodipine 10 mg PO DAILY
3. Baclofen 10 mg PO QID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
2. Baclofen 10 mg PO QID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. CefePIME 1 g IV Q12H
RX *cefepime [Maxipime] 1 gram 1 gram intravenously every 12
hours Disp #*18 Vial Refills:*0
5. Amlodipine 10 mg PO DAILY
6. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Urinary Tract Infection
Secondary:
- Neurogenic Bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with inability to advance PICC by IV team at
bedside. // ___ repo
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ resident Dr. ___,
___ and Dr. ___ radiologist performed
the procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 2.8 min, 2 mGy
PROCEDURE: Replacement of left PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC was aspirated and flushed and a Nitinol guidewire was introduced into the
superior vena cava (SVC). The exisiting PICC was removed. A peel-away sheath
was then placed over the guidewire. The guidewire was then advanced into the
superior vena cava. A single lumen PICC measuring 47 cm in length was then
placed through the peel-away sheath with its tip positioned in the lower SVC
under fluoroscopic guidance. Position of the catheter was confirmed by a
fluoroscopic spot film of the chest. The peel-away sheath and guidewire were
then removed. The catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
Existing left arm approach PICC with tip in the left axilla was replaced with
a new single lumen PICC with tip in the lower SVC.
IMPRESSION:
Successful placement of a 47 cm left arm approach single lumen PICC with tip
in the lower SVC. The line is ready to use.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: UTI SX
Diagnosed with URIN TRACT INFECTION NOS, DEHYDRATION
temperature: 99.4
heartrate: 88.0
resprate: 20.0
o2sat: 100.0
sbp: 144.0
dbp: 67.0
level of pain: 4
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
============================
___ with PMHx of paraplegia with neurogenic bladder and frequent
UTIs admitted for complicated UTI (46 WBCs on UA, few bacteria).
Started on IV cefepime. Urine cx revealed mixed bacterial flora,
consistent with fecal contamination. Treated with 10-day course
of IV cefepime given history of recurrent UTIs. Urine culture
showed mixed bacterial flora, consistent with fecal
contaminants. Repeat urine culture was not ordered since patient
had already received several doses of IV cefepime. By time of
discharge, (treatment day #2), patient's symptoms had resolved
entirely. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
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:
___ year old ___ man with PMH of schizophrenia,
dementia, right frontoparietal craniotomy presents from ___
___ assisted living after a witnessed fall.
Per ED discussion with family, he appeared at his baseline
mental status and orientation. He was complaining of right
shoulder/elbow pain, otherwise no complaints. Per discussion
with RN at ___, he has had ___ weeks of altered
behavior. He has been more violent toward the other residents,
whereas usually he has a very affable demeanor. His baseline
mental status is awake, alert and pleasant, but with decreased
situational awareness, and unable to advocate for himself or
describe symptoms.
His nurse reports that he saw his doctor ___ this
past week for the increased violent behavior, although she is
not sure what was done for him if anything.
In the ED, initial vitals were: 98.3, 103, 159/89, 18, 96% RA
Exam notable for bloody sputum at corners of mouth, trauma
survey unremarkable. He had one episode of emesis/frothy sputum
but no other abdominal symptoms or findings. Also noted to have
brief hypoxia and wheezing while sleeping which resolved
spontaneously.
UA revealed large leuks, positive nitrites, many bacteria.
Labs notable for Cr 3.4, BUN 38 (no known baseline), Hb 12.1,
WBC 8.1, lactate 1.1.
Imaging notable for:
CT head and C-spine negative; right shoulder/elbow xrays: no
fracture or misalignment,
CXR: borderline cardiomegaly but rotated, no ptx, no rib fx.
Patient was given his home metoprolol and keppra, as well as 1g
CTX IV.
Decision was made to admit for treatment of UTI.
Vitals on transfer: 98.4, 92, 143/84, 20, 97% RA
On the floor, pt is somnolent but rouses to voice. Answers that
he is in the hospital but not sure which hospital. Further
history to be obtained once ___ interpreter is available.
Review of systems:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-Schizoprhenia
-Dementia
-?Sz disorder
-CKD
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 98.5, 135 / 82, 85, 20, 97% Ra
Gen: Sleepy, rouses to voice, NAD
HENT: NC/AT. Dry MM.
Eyes: No scleral icterus.
CV: RRR no r/m/g
Pulm: CTAB
Abd: Soft, non-tender, non-distended
GU: No foley
Ext: WWP, no peripheral edema
Skin: warm, dry
Neuro: Sleepy, rouses to voice. Alert to person, hospital. No
gross deficits.
Psych: Unable to assess
DISCHARGE PHYSICAL EXAM:
==========================
Vitals: 98.1, 124 / 73, 78 18 92 Ra
Gen: Awake, alert
HENT: NC/AT. MMM.
Eyes: No scleral icterus.
CV: RRR no r/m/g
Pulm: CTAB
Abd: Soft, non-tender, non-distended
GU: No foley
Ext: WWP, no peripheral edema. R hip with no obvious ecchymosis,
bony abnormality, non-tender to palpation. Apparent pain with
external rotation of the hip. Full ROM at the R knee with no
bony abnormality and non-tender to palpation.
Skin: warm, dry
Neuro: Awake, alert to person, hospital. Tardive dyskinesia.
Psych: Agreeable affect
Pertinent Results:
ADMISSION LABS:
___ 09:18PM BLOOD WBC-8.1 RBC-3.86* Hgb-12.1* Hct-37.4*
MCV-97 MCH-31.3 MCHC-32.4 RDW-11.6 RDWSD-40.9 Plt ___
___ 09:18PM BLOOD Glucose-158* UreaN-38* Creat-3.4* Na-137
K-4.3 Cl-99 HCO3-20* AnGap-22*
___ 09:18PM BLOOD ALT-15 AST-24 AlkPhos-96 TotBili-0.8
___ 09:18PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.2 Mg-2.3
___ 11:27PM URINE Blood-TR Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 11:27PM URINE RBC-5* WBC-93* Bacteri-MANY Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 10:35AM BLOOD WBC-4.5 RBC-3.30* Hgb-10.9* Hct-32.5*
MCV-99* MCH-33.0* MCHC-33.5 RDW-11.9 RDWSD-42.8 Plt ___
___ 10:35AM BLOOD Glucose-242* UreaN-36* Creat-2.9* Na-136
K-4.1 Cl-104 HCO3-18* AnGap-18
___ 10:35AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
MICROBIOLOGY:
___ 11:27 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CT head:
Postsurgical changes are seen following right frontoparietal
craniotomy.
Otherwise, no acute major intracranial process.
CT Cspine:
1. No evidence of acute fracture. There is minimal
anterolisthesis of the
C3-C4 vertebral level, likely degenerative in etiology. Please
correlate
clinically for focal pain at this level.
2. Mild-to-moderate degenerative changes in the cervical spine
with mild
multilevel vertebral canal and neural foraminal stenosis.
3. Mild thickening of the esophagus may reflect esophagitis.
Please correlate with clinical exam.
Right Shoulder Xray:
Mild arthritis, no fracture or dislocation.
Right Elbow:
No fracture or dislocation
Chest Xray:
AP portable supine view of the chest. Patient is slightly
rotated 2 the
right. Widened mediastinum may be technique related. Lungs are
clear.
Cardiac silhouette appears normal in size. No large effusion or
definite
signs of pneumothorax on this supine radiograph. Bony
structures are intact.
Limited, negative.
Renal ultrasound:
1. No evidence of hydronephrosis, nephrolithiasis, or
perinephric fluid
collection bilaterally.
2. There is thickening and irregularity of the posterior aspect
of the
bladder which likely represents trabeculation. However, a
bladder mass cannot be excluded based on this exam. Consider
more detailed evaluation if desired with more completely
distended bladder
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Acetate 1334 mg PO BID
2. Benztropine Mesylate 1 mg PO BID
3. Haloperidol 2 mg PO QHS
4. Haloperidol Decanoate (long acting) 100 mg IM Frequency is
Unknown
5. LevETIRAcetam 250 mg PO BID
6. Metoprolol Tartrate 50 mg PO BID
7. Senna 17.2 mg PO QHS:PRN constipation
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
last day ___
2. Benztropine Mesylate 1 mg PO BID
3. Calcium Acetate 1334 mg PO BID
4. Haloperidol Decanoate (long acting) 100 mg IM ONCE Duration:
1 Dose
5. Haloperidol 2 mg PO QHS
6. LevETIRAcetam 250 mg PO BID
7. Metoprolol Tartrate 50 mg PO BID
8. Senna 17.2 mg PO QHS:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Urinary tract infection
Secondary diagnosis:
acute kidney injury
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 U.S.
INDICATION: ___ year old man with post-void residual of 550, dirty UA // eval
for obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 9.2 cm. The left kidney measures 10.4 cm. The
kidneys appear atrophic and more echogenic, with decreased corticomedullary
differentiation. There is a 1.2 cm cyst in the left upper renal pole. There
is no visualized hydronephrosis, stones, or masses bilaterally.
The bladder is partially distended. There is irregularity and thickening of
the posterior aspect of the bladder which is likely due to trabeculation
however, a bladder mass is not excluded.
IMPRESSION:
1. No evidence of hydronephrosis, nephrolithiasis, or perinephric fluid
collection bilaterally.
2. There is thickening and irregularity of the posterior aspect of the
bladder which likely represents trabeculation. However, a bladder mass cannot
be excluded based on this exam. Consider more detailed evaluation if desired
with more completely distended bladder
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:18 pm, 20 minutes after
discovery of the findings.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: R Elbow pain, s/p Fall
Diagnosed with Altered mental status, unspecified, Urinary tract infection, site not specified, Chronic kidney disease, unspecified
temperature: 98.3
heartrate: 103.0
resprate: 18.0
o2sat: 96.0
sbp: 159.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | ___ year old ___ man with PMH of schizophrenia,
dementia, right frontoparietal craniotomy presents from ___
___ after a witnessed fall i/s/o ___ weeks of
altered behavior, found to have a UTI. Treated with ceftriaxone
with improvement in mental status to baseline, and transitioned
to ciprofloxacin to complete a 10 day course for complicated
UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / valproic acid / ibuprofen / propofol / chlorhexidine /
cefazolin / cefazolin / levofloxacin / dexmedetomidine /
bupivacaine / divalproex sodium
Attending: ___.
Chief Complaint:
HD CATH REPLACEMENT
Major Surgical or Invasive Procedure:
Replacement of tunneled dialysis line
History of Present Illness:
___ with history of ESRD (HD TRS), fell down steps yesterday,
seen at ___ where he had CT head and chest, but
no neck, he was discharged home. Pt believe his catheter may
have broke during fall. Today he presents because he rolled over
in bed overnight and dialysis port came out. Of note, pt is an
extremely poor historian and cannot relay a good sequence of
events. Pt has never been seen at ___ before.
In the ED, Had C-spine here which was negative. CXR showed
mild-moderate pulmonary edema. The patient was evaluated by the
interventional fellow regading cath tip replacement with plan to
replace tomorrow.
In the ED, initial VS were 98.4 84 117/49 12 100% RA.
Exam notable for palpable fibrous tract that was surrounding the
catheter, as well as forehead scrape.
Labs showed macrocytic anemia with hgb 8.7, plt 136, Na 131, K
5.2, Cl 94.
Imaging showed CT Head without acute intracranial process, CT
C-spine without fracture, and CXR with mild/moderate pulmonary
edema.
___ was consulted and will likely replace catheter tomorrow.
Vascular surgery was consulted for possibility of retained
catheter tip, but they deemed the catheter tip intact.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports a history of falls
starting approximately 5 months ago. He does not lose
consciousness. Feels unsteady with his gait. ___ was going to see
him at his home.
Past Medical History:
ESRD, on HD ___
Chronic Back Pain
L Foot pain
PTSD
Schizophrenia
Anxiety
Deprssion
LUE fistula
Social History:
___
Family History:
Mother with diabetes, HTN, HLD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.9 129/59 887 18 100%RA
GENERAL: NAD, flat affect
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs. Area of
tunneled line open, c/d/I. Fibrous tract can be felt.
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. LUE with fistula and good thrill
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS - 97.9 123/52 85 18 100%
GENERAL: NAD, brighter affect
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CHEST : RRR, S1/S2, no murmurs, gallops, or rubs. Tunneled HD
catheter in bandage. Site of insertion c/d/I, nontender
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. LUE with fistula and good thrill
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, decreased proprioception in bilateral
great toes. Sensation to light touch intact. Strength ___ ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 03:00AM BLOOD WBC-6.1 RBC-2.65* Hgb-8.7* Hct-26.9*
MCV-102* MCH-32.8* MCHC-32.3 RDW-21.3* RDWSD-78.7* Plt ___
___ 03:00AM BLOOD Neuts-69.8 Lymphs-15.5* Monos-9.5 Eos-3.4
Baso-1.5* Im ___ AbsNeut-4.26 AbsLymp-0.95* AbsMono-0.58
AbsEos-0.21 AbsBaso-0.09*
___ 02:00PM BLOOD ___
___ 03:00AM BLOOD Glucose-93 UreaN-26* Creat-3.7* Na-131*
K-5.2* Cl-94* HCO3-28 AnGap-14
___ 03:00AM BLOOD ALT-20 AST-49* AlkPhos-100 TotBili-0.8
___ 03:00AM BLOOD Albumin-3.5
___ 07:40AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-1.9
___ 06:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-POS mthdone-NEG
MICRO: none
IMAGING:
EKG ___: Sinus rhythm. Q-T interval is borderline prolonged
for rate. Leftward axis.
Prominent voltage raises the possibility of left ventricular
hypertrophy.
Non-specific ST-T wave abnormalities may be related to left
ventricular
hypertrophy. No previous tracing available for comparison.
CT Head/ CT C-spine ___: No acute intracranial process. No
acute fracture or vertebral malalignment.
CXR ___: Mild to moderate pulmonary edema. Cardiomegaly.
Tunneled Dialysis Line Placement ___: Successful placement of
a 23cm tip-to-cuff length tunneled dialysis line. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
DISCHARGE LABS:
___ 08:02AM BLOOD WBC-6.6 RBC-2.92* Hgb-9.3* Hct-29.8*
MCV-102* MCH-31.8 MCHC-31.2* RDW-20.5* RDWSD-77.3* Plt ___
___ 08:02AM BLOOD Glucose-94 UreaN-49* Creat-5.5* Na-133
K-5.2* Cl-96 HCO3-25 AnGap-17
___ 07:40AM BLOOD ALT-16 AST-36 LD(LDH)-418* AlkPhos-99
TotBili-0.9
___ 08:02AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
___ 07:40AM BLOOD VitB12-811
___ 09:20AM BLOOD %HbA1c-5.2 eAG-103
___ 07:40AM BLOOD TSH-12*
___ 08:02AM BLOOD T4-6.5 T3-68*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 600 mg PO Frequency is Unknown
4. Vitamin D 1000 UNIT PO DAILY
5. ClonazePAM 1 mg PO Frequency is Unknown
6. Nephrocaps 1 CAP PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. LeVETiracetam 250 mg PO BID
9. Lisinopril 2.5 mg PO DAILY
10. Metoprolol Tartrate 12.5 mg PO DAILY
11. OLANZapine 2.5 mg PO QHS
12. OLANZapine 5 mg PO DAILY
13. Omeprazole 20 mg PO Frequency is Unknown
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
15. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is
Unknown pain
16. Polyethylene Glycol 17 g PO DAILY
17. sevelamer CARBONATE 2400 mg PO TID W/MEALS
18. Simvastatin 20 mg PO QPM
19. TraZODone 50 mg PO QHS
Discharge Medications:
1. Amphetamine-Dextroamphetamine XR 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
do not drink alcohol or drive while on this medication
RX *clonazepam 0.5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. LeVETiracetam 250 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. OLANZapine 2.5 mg PO QHS
10. OLANZapine 5 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
do not drink alcohol or drive while on this medication
13. Polyethylene Glycol 17 g PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Simvastatin 20 mg PO QPM
16. TraZODone 50 mg PO QHS
17. Vitamin D 1000 UNIT PO DAILY
18. Acetaminophen 1000 mg PO Q8H:PRN pain
do not exceed 3g in a day (3 pills)
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*75 Tablet Refills:*0
19. Calcium Carbonate 500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
End Stage Renal Disease on Dialysis
Recurrent Falls
Schizophrenia
Chronic Anemia
Hyponatremia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with head strike and LOC // R/O acute process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 48.9 mGy (Head) DLP =
802.7 mGy-cm.
4) Sequenced Acquisition 4.0 s, 4.1 cm; CTDIvol = 48.9 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
The examination is slightly motion degraded. Within these confines:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
There is no evidence of fracture. There are small mucous retention cyst in
the right frontal sinus. Otherwise, the visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with head strike and LOC // R/O acute process
R/O acute process
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.0 s, 23.3 cm; CTDIvol = 37.3 mGy (Body) DLP = 871.0
mGy-cm.
Total DLP (Body) = 871 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no acute fracture or vertebral malalignment. Degenerative changes
are noted throughout the C-spine, most prominent at C6-7 with endplate
sclerosis and disc space narrowing. There is no evidence of spinal canal or
neural foraminal stenosis. There is no prevertebral soft tissue swelling.
There is no evidence of infection or neoplasm.
IMPRESSION:
No acute fracture or vertebral malalignment.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: History: ___ with fall, dialysis catheter traumatically removed
from R-side // evaluate for pneumothorax, acute process
TECHNIQUE: Single portable supine AP image of the chest.
COMPARISON: None.
FINDINGS:
The lungs are well expanded. There are perihilar opacities and reticular
opacities, consistent with mild to moderate pulmonary edema. There are no
pleural effusions or pneumothorax. The cardiomediastinal silhouette
demonstrates moderate to severe enlargement
IMPRESSION:
Mild to moderate pulmonary edema. Cardiomegaly.
Radiology Report
INDICATION: ___ year old man with ESRD and recently removed tunneled dialysis
catheter. Pt was consulted on in ED. // Replacement of tunneled dialysis line
COMPARISON: Chest radiograph of ___.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
personally supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 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.
FLUOROSCOPY TIME AND DOSE: 1.8 min, 3 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was partially compressible and accessed using a micropuncture needle.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. Subsequently a Nitinol wire was passed into the
right atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. ___ subcuticular Vicryl sutures and Steri-strips were also used to
close the venotomy incision site. Final spot fluoroscopic image demonstrating
good alignment of the catheter and no kinking. The tip is in the right atrium.
The catheter was flushed and both lumens were capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Partially thrombosed right internal jugular vein. Final fluoroscopic image
showing tunneled hemodialysis catheter with tip terminating in the right
atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The
tip of the catheter terminates in the right atrium. The catheter is ready for
use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Oth complication of vascular prosth dev/grft, init, Exposure to other specified factors, initial encounter, Chronic kidney disease, unspecified
temperature: 98.4
heartrate: 84.0
resprate: 12.0
o2sat: 100.0
sbp: 117.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo M with ESRD on T/R/S dialysis, immature LUE
fistula, schizophrenia, PTSD, ADHD, depression, and chronic back
pain who presented after tunneled dialysis catheter was
completely withdrawn s/p fall. Patient had previously been
evaluated for fall at ___, noting facial
lacerations and left rib fractures. The next day he noticed his
catheter fell out and came to ___ for replacement. Given his
recent trauma, CT head and CT C-spine were performed, both of
which did not reveal acute pathology. Patient's tunneled
dialysis line was replaced and he received dialysis in house
___. He tolerated 500cc of his goal 1L ultrafiltration, before
becoming anxious. He also reported a 5 month history of
instability and recurrent falls. On exam, he had some evidence
of bilateral peripheral neuropathy. B12 and A1c were within
normal limits, TSH returned elevated at 12; T3, T4 were pending
at the time of discharge. He was evaluated by ___ who recommended
discharge home with continued ___ services.
# Fall: Patient had a recent fall, for which he had a CT head
and c-spine which were without acute abnormality. Patient is a
poor historian. CXR and UA without signs of localizing
infection. Urine toxicology positive for opiates, which patient
takes at home. Spoke with patient's wife who reports he has some
difficulty mentating at baseline. Has been falling more over the
past 5 months. Patient at baseline seems to be AAOx2-3 with
difficulty naming months of year backwards. Per ___ record,
patient was on Oxycodone 5mg q4h PRN as well as Percocet ___
q8hrs PRN. He was also on clonazepam 1mg tid PRN anxiety, as
well as trazodone and olanzapine. In an effort to consolidate
sedating medications, his pain regimen was titrated to Oxycodone
5mg q6h PRN pain and his clonazepam titrated to 0.5mg tid PRN
anxiety. Patient was planned to have ___ at home, which was
reinforced by inpatient ___ assessment. Evaluation for peripheral
neuropathy revealed B12, A1C within normal limits. TSH was
elevated at 12 with normal T4 and low T3.
# End Stage Renal Disease: Hemodialysis ___, s/p left AV
fistula. Had been getting HD via right tunneled line which fell
out after fall. This was replaced in ___ and patient received
half session of dialysis, stopped secondary to anxiety. Patient
has a LUE that seems close to maturation and was to be evaluated
by his vascular surgeon outpatient. While inpatient, he was
continued on sevelamer, nephrocaps, and lisinopril.
# Schizophrenia: Continued olanzapine, trazodone, and
clonazepam. Clonazepam was decreased from 1mg to 0.5mg q8hr PRN
anxiety.
#ADHD: Continued on Amphetamine-Dextroamphetamine XR 20 mg PO
DAILY
# Anemia: Admission H/H 8.7/26.9, likely chronic secondary to
ESRD. No signs and symptoms of active bleeding.
- Continue to monitor
# Hyponatremia: Resolved. Likely in the setting of volume
overload and missed ESRD session.
TRANSITIONAL ISSUES
- Patient received half-dialysis session ___ stopped early
secondary to patient anxiety. Ultrafiltration of 500cc of goal
1000cc. He should continue his ___
dialysis schedule.
- Patient has purse-string stitch on right HD line which should
be removed at his next dialysis date, ___.
- Per ___ record, patient was on Oxycodone 5mg q4h PRN as well
as Percocet ___ q8hrs PRN. He was also on clonazepam 1mg tid
PRN anxiety, as well as trazodone and olanzapine. In an effort
to consolidate sedating medications, his pain regimen was
titrated to Oxycodone 5mg q6h PRN pain and his clonazepam
titrated to 0.5mg tid PRN anxiety. Further adjustments to his
pain regimen and anxiolysis at the discretion of PCP.
- Patient with recurrent falls, including one down a flight of
stairs. To continue to work with home ___ but may need further
evaluation for gait instability. B12, A1c WNL this admission,
TSH elevated to 12. T3 of 68, T4 of 6.5
- Patient was to have appointment with vascular surgeon to
assess maturity of LUE fistula while inpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / ACE Inhibitors
Attending: ___.
Chief Complaint:
Lower extremity weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of hypertension, atrial fibrillation, complete
heart block s/p PPM, presenting with inability to ambulate
starting the morning of presentation.
Patient has been having months of myalgias. For the past few
months, the patient has had multifocal myalgias and arthralgias
(shoulder, back, feet), and sensation of lower extremity
heaviness. For the past month, he has been able to ambulate at
home for about ___, then becomes fatigued and complains of L
hernia bulge. Over the past month his relative has been
assisting him with getting dressed in the morning and perform
daily activities. On morning of admission, he again had
bilateral lower extremity heaviness with inability to bear
weight independently, for which was brought to ___ ED.
Patient states it is been having diarrhea in the past as well
as possibly urinary incontinence when he has the diarrhea. No
recent travel. No numbness or tingling.
He has noticed word-finding difficulties, but no change in
speech or comprehension. Chronic mild headaches. Occasional
posterior neck and lower back pain. No vomiting, diarrhea,
seizures, change in vision, coordination. Urinary frequency with
post-micturitional dribbling, no constipation. Subjective fever
last night. Nighttime dry mouth without dysphagia.
He was seen for similar complaints by PCP ___ ___, with
serologic evaluation unremarkable (ESR 9, ___ negative, CCP <16,
CRP 0.9, RF <10) and considered referral to Ortho v. Rheum.
In the ED, initial VS were:
98.2
84
159/81
100% RA
Code Cord was called due to ___ weakness and lack of reflexes.
CT spine was done (MRI not obtained due to Pacemaker).
Labs showed: Mg 1.5, Phos 2.3, Lactate 2.7. Otherwise
unremarkable.
Imaging showed:
CT T/L Spine ___
1. No evidence of a mass lesion causing high-grade spinal canal
stenosis in the thoracic and vertebral spine.
2. No evidence of fracture or traumatic malalignment in the
thoracic or lumbar spine.
3. Mild to moderate thoracic and lumbar spondylosis.
4. Common bile duct is enlarged, measuring up to 1.0 cm, but
tapers normally at the level of the ampulla. Please correlate
with LFTs if there is concern for biliary obstruction.
5. Cholelithiasis, incompletely imaged.
CT Head ___
No acute intracranial process
Neurology was consulted and involved in the above w/u imaging
discussion but given largely unremarkable results, felt that no
further neurologic evaluation was needed.
Decision was made to admit to medicine for further management
of weakness.
On arrival to the floor, patient interviewed with ___
translator on the phone for 30 minutes. Unfortunately, the
patient is argumentative and continues to state that he is here
for weakness that has been going on for a while, however acutely
worsened this AM leading to inability to stand (notably, the
patient stood and ambulated to the scale on admission). He
denies any recent fevers, chills, weight loss, N/V or other
infectious symptoms. He reports diarrhea 4 months ago that is
completely resolved. He struggles to understand orientation
questions but limited ___ phone interpreter.
Past Medical History:
HTN
HERNIA
GYNECOMASTIA
PROSTATE NODULE
ATRIAL FIBRILLATION
COMPLETE HEART BLOCK ___ s/p PPM
NISSEN FUNDIPLOCATION in ___ ___
H/O MACROCYTOSIS
nl b12, folate
Social History:
___
Family History:
Unable to give a meaningful family history due to mental status
Physical Exam:
ADMISSION EXAM:
VS - 98.0; 172 / 82; 77; 18 96 RA
GENERAL: NAD, lying in bed, well appearing
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Notable strength ___ in bilateral
extremities - patient raises both legs and keeps off bed to
active resistence.
PULSES: 2+ DP pulses bilaterally
NEURO: Oriented to name, hospital, limited by translation on
phone. CN2-12 testing limited because there is no interpreter
available
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: 98.2, 151/77, HR 7, RR 18, 96% RA
GENERAL: NAD, lying in bed, well appearing
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender, no organomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: a&ox3, normal speech, ___ strength in UE and ___,
sensation in tact to light touch, able to walk with wide-based
gait
SKIN: warm and well perfused, no rashes
Pertinent Results:
Admission labs:
___ 12:50PM BLOOD WBC-6.9 RBC-4.24* Hgb-14.0 Hct-41.5
MCV-98 MCH-33.0* MCHC-33.7 RDW-13.6 RDWSD-49.0* Plt ___
___ 12:50PM BLOOD Neuts-66.1 ___ Monos-7.4 Eos-1.0
Baso-0.4 Im ___ AbsNeut-4.56 AbsLymp-1.71 AbsMono-0.51
AbsEos-0.07 AbsBaso-0.03
___ 12:50PM BLOOD Glucose-121* UreaN-16 Creat-0.9 Na-142
K-3.4 Cl-99 HCO3-29 AnGap-17
___ 12:50PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.5*
___ 01:30PM BLOOD Lactate-2.7*
Discharge labs:
___ 05:55AM BLOOD WBC-6.5 RBC-3.92* Hgb-12.8* Hct-37.9*
MCV-97 MCH-32.7* MCHC-33.8 RDW-14.0 RDWSD-49.6* Plt ___
___ 05:55AM BLOOD Neuts-58.4 ___ Monos-11.1 Eos-2.5
Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-1.75 AbsMono-0.72
AbsEos-0.16 AbsBaso-0.03
___ 05:55AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-145
K-2.6* Cl-101 HCO3-30 AnGap-17
___ 05:55AM BLOOD ALT-23 AST-31 LD(LDH)-214 AlkPhos-115
TotBili-0.7
___ 05:55AM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.4 Mg-2.1
Imaging:
CT T/L Spine ___
1. No evidence of a mass lesion causing high-grade spinal canal
stenosis in the thoracic and vertebral spine.
2. No evidence of fracture or traumatic malalignment in the
thoracic or lumbar spine.
3. Mild to moderate thoracic and lumbar spondylosis.
4. Common bile duct is enlarged, measuring up to 1.0 cm, but
tapers normally at the level of the ampulla. Please correlate
with LFTs if there is concern for biliary obstruction.
5. Cholelithiasis, incompletely imaged.
CT Head ___
No acute intracranial process
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL
___ ml by mouth QID:prn Refills:*0
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
3. HydrALAZINE 50 mg PO QID
RX *hydralazine 50 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*1
4. Potassium Chloride 20 mEq PO DAILY
Hold for K > 5
RX *potassium chloride [K-Tab] 20 mEq 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*1
5. Ranitidine 75 mg PO DAILY:PRN indigestion
RX *ranitidine HCl [Acid Reducer (ranitidine)] 75 mg 1 tablet(s)
by mouth daily: prn Disp #*30 Tablet Refills:*1
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. amLODIPine 10 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9.Rolling walker
Diagnosis: Hypokalemia
Prognosis: Good
Length of need: 13 months
10.Outpatient Occupational Therapy
Treat and evaluate: 12 weeks, 3 sessions/week
ICD-10: ___ Generalized muscle weakness
11.Outpatient Physical Therapy
Treat and evaluate: 12 sessions, 3 sessions/week
ICD 10: ___ Generalized muscle weakness
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Hypokalemia
Hypomagnesemia
Hypertension
Secondary diagnosis:
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
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with lower extremity paralysis bilaterally // ?mass
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 18.0 s, 19.1 cm; CTDIvol = 47.3 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
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 involutional changes. Ill-defined periventricular and subcortical
white matter hypodensities are nonspecific but likely due to sequela of
small-vessel ischemic disease.
Sclerosis of the right sphenoid sinus suggest prior chronic inflammation.
Mild mucosal thickening is seen involving the sphenoid and posterior ethmoid
air cells. The imaged paranasal sinuses are otherwise clear. Mastoid air
cells and middle ear cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT T-SPINE W/ CONTRAST
INDICATION: ___ year old man with pacemaker unable to get MRI with acute ___
weakness // ?cord compression
TECHNIQUE: Contrast-enhanced helical multidetector CT was performed. 100 cc
of Omnipaque 350 intravenous contrast was administered. Soft tissue and bone
algorithm images were generated. Coronal and sagittal reformations were then
constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.9 s, 54.3 cm; CTDIvol = 32.9 mGy (Body) DLP =
1,785.3 mGy-cm.
Total DLP (Body) = 1,785 mGy-cm.
COMPARISON: None.
FINDINGS:
THORACIC SPINE:
Alignment is normal. No fractures are identified. Mild to moderate multilevel
degenerative changes are noted with bridging anterior osteophytes. There is
mild narrowing of the left posterior aspect of the spinal canal at the T2-T3
vertebral level due to left uncovertebral hypertrophy as well as ligamentum
flavum thickening and calcification. There is no evidence of high-grade
central canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. No abnormal
enhancement is seen.
LUMBAR SPINE:
Alignment is normal. No fractures are identified. Mild multilevel
degenerative changes are seen with mild anterior osteophytes. Small disc
bulges are noted at L4-5 and L5-S1 with slight flattening of the ventral
aspect of the thecal sac. Mild neural foraminal narrowing is noted
bilaterally at L3-4, L4-5 and L5-S1 with facet arthropathy. There is no
evidence of high-grade spinal canal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. No abnormal
enhancement is seen.
Limited views of the chest are remarkable for mild atelectasis. Pacemaker
wires are partially visualized.
Limited views of the abdomen are remarkable for bilateral renal simple cysts,
with the largest measuring up to 3.8 cm in the interpolar region of the left
kidney. Atherosclerotic calcifications are seen throughout the thoracic and
abdominal aorta. The common bile duct is enlarged measuring up to 1.0 cm but
tapers normally to the level of the ampulla (series 3: Image 131).
Cholelithiasis is incidentally seen.
IMPRESSION:
1. No evidence of a mass lesion causing high-grade spinal canal stenosis in
the thoracic and vertebral spine.
2. No evidence of fracture or traumatic malalignment in the thoracic or lumbar
spine.
3. Mild to moderate thoracic and lumbar spondylosis.
4. Common bile duct is enlarged, measuring up to 1.0 cm, but tapers normally
at the level of the ampulla. Please correlate with LFTs if there is concern
for biliary obstruction.
5. Cholelithiasis, incompletely imaged.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Weakness, Body pain
Diagnosed with Weakness
temperature: 98.2
heartrate: 84.0
resprate: nan
o2sat: 100.0
sbp: 159.0
dbp: 81.0
level of pain: unable
level of acuity: 2.0 | ___ with history of hypertension, atrial fibrillation, complete
heart block s/p PPM, presenting with acute lower extremity
weakness found to be hypokalemic
# Lower extremity weakness: Endorses weakness for several months
but acutely worse on day of admission. Differential is broad,
but most likely cause is hypokalemia, given his K 2.6 on
admission. Other causes include PVD, neuropathy, other
electrolyte abnormalities, deconditioning. Neuro imaging in ED
was unremarkable, and neuro saw the patient and suggested that
his symptoms are unlikely to be from an acute neurologic
process. We repleted his K and his condition greatly improved.
We started KCl 20 mEq PO daily for him to continue as an
outpatient.
# Hypokalemia: K of 2.6 on admission. EKG was unchanged from
___, and patient does not endorse chest pain or palpitations.
Likely cause is GI losses from his prolonged diarrhea (reported
history of 6 months of diarrhea). We started potassium
supplementation with KCl tablets 20 mEq daily. He may also have
hyperaldosteronism as is renin level was low, aldosterone level
was pending at the time of discharge. He will follow-up in
___ clinic on ___.
-- At the time this discharge summary was signed, the
aldosterone level had resulted, and was also low. I have
reached out to Dr. ___ endocrinologist who will be seeing
him in follow-up to see if there is any further testing I can
help facilitate prior to his appointment. This could be
explained by congenital adrenal hyperplasia, ___ syndrome,
etc.
# Diarrhea: Endorses 6 months of diarrhea. Unknown cause. Stool
culture and o&p were negative. He may also have lactose
intolerance, as only certain foods exacerbate his diarrhea. We
started him on Maalox and zantac prn for abdominal discomfort
and indigestion. He may need an EGD as an outpatient to evaluate
his anatomy, as he may have a component of malabsorption from
past ___ fundoplication.
# Hypertensive urgency: Continued home Amlodipine 10mg qD,
Losartan 100mg qD. Started hydralazine 50 mg PO QID for
hypertension. Started carvedilol 25 mg PO BID in place of
metoprolol. Renin level is low. Aldosterone level, pending at
discharge, is also low, which may be consistent with a
mineralocorticoid excess syndrome. As above, he will follow-up
with endocrine as an outpatient.
# Metabolic encephalopathy / Delirium: Had significant hospital
acquired delirium. His mental status improved with reorientation
and family at bedside, and he was back to his baseline prior to
discharge.
# A-Fib: V-paced. Not on anticoagulation, and PCP reasoned that
his risks may outweigh benefits, and he may not reliably take
warfarin. Dc'ed his home metoprolol and started carvedilol 25 mg
PO BID for better BP control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of triple negative metastatic breast cancer
treated with palliative chemo (eribulin C1D8 as of ___,
DM1 c/b gastroparesis presenting with acute onset abdominal
pain,
subjective fevers, chills, vomiting >20x, diarrhea ___. These
symptoms started one day after receiving chemotherapy on ___.
She has not noted any blood in vomit or stool. Her pain is
___,
periumbilical, without any alleviating factors.
She had some nausea after her first round of chemo, but did not
have symptoms like this. No sick contacts, new foods, or travel.
She denies any h/o DKA or requiring hospitalization for her type
I diabetes. She denies any CP, SOB, leg swelling, urinary
symptoms, or weakness.
ED course:
O: 97.9 110 169/99 20 99%
meds
23:14 Lovenox 60 mg SC
20:20 Morphine Sulfate 5 mg IV
19:00 Ondansetron 4 mg IV
19:00 Morphine Sulfate 5 mg IV
rads
20:36 CT ABD & PELVIS WITH CONTRAST
iv
20:20 40 mEq Potassium Chloride / 1000 mL NS Continuous at
250 ml/hr for 1000 ml
Review of Systems: As per HPI. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative on palliative chemo (eribulin C1D8 as of
___
-please see OMR for full onc history details
PMH:
- T1DM (hemoglobin A1c ___ was 10.2%) complicated by
gastroparesis
- LUE DVT on lovenox
- Left lymphedema
- HTN
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia, syphilis
Social History:
___
Family History:
Diabetes and hypertension, both run in the
family, but there is no known family history of breast cancer.
Physical Exam:
ON ADMISSION:
98.9, 164/92, 102, 16, 95%RA
GEN: NAD, reclined in bed
HEENT: PERRL, EOMI, slightly dry mucosal membranes, oropharynx
clear, no cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR with II/VI SEM, nl S1 S2. JVP<7cm
Chest: R sided port without surrounding erythema, swelling, TTP
ABD: normal bowel sounds, soft, not distended. +mild TTP in
epigastric area.
EXTR: Warm, well perfused. left UE lymphedema. 2+ radial and DP
pulses.
NEURO: alert and orientedx3, motor grossly intact
ON DISCHARGE:
Still with Left upper extremity edema, improving per patient.
Pertinent Results:
___ 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-150 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:50PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:05PM LACTATE-1.5
___ 06:52PM GLUCOSE-256* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
___ 06:52PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-91 TOT
BILI-0.2
___ 06:52PM LIPASE-24
___ 06:52PM ALBUMIN-3.9
___ 06:52PM WBC-9.2# RBC-3.46* HGB-10.2* HCT-32.3*#
MCV-93 MCH-29.6 MCHC-31.7 RDW-13.0
___ 06:52PM PLT COUNT-448*
ON DISCHARGE:
___ 09:43AM BLOOD Neuts-50.8 Lymphs-44.5* Monos-4.2 Eos-0.4
Baso-0.1
___ 09:43AM BLOOD Glucose-186* UreaN-11 Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-33* AnGap-11
MICRO:
___ BLOOD CULTURE Blood Culture,
Routine-FINAL neg EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-FINAL negEMERGENCY WARD
___ URINE URINE CULTURE-FINAL negEMERGENCY
WARD
CT ABD/PELVIS ___
The visualized lung bases again demonstrate innumerable
pulmonary nodules as well as necrotic left breast mass. The
patient is status post right mastectomy. The liver, gallbladder,
spleen, bilateral adrenal glands, pancreas, stomach, and
visualized loops of small large bowel are within normal limits.
Bilateral kidneys are normal with no evidence of hydronephrosis
or stones. The appendix is not clearly visualized but there are
no secondary signs of appendicitis. There is no free fluid or
free air. There is no mesenteric or retroperitoneal
lymphadenopathy. Abdominal aorta is normal in caliber. There is
no free air or free fluid. CT PELVIS WITH IV CONTRAST: The
uterus appears within normal limits with an IUD in place. The
rectum, sigmoid colon, and bladder appear unremarkable. There is
a small amount of free fluid, likely physiologic. OSSEOUS
STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy. Mild diffuse body anasarca is again
noted. Subcutaneous gas is noted in the anterior subcutaneous
tissues, likely from injections. IMPRESSION:
1. No acute abdominal or pelvic process.
2. Visualized lung bases again demonstrate innumerable pulmonary
nodules as well as a necrotic left breast mass.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 60 mg SC Q12H
2. Citalopram 20 mg PO DAILY
3. Ibuprofen 600 mg PO Q6H:PRN pain
4. TraMADOL (Ultram) 50 mg PO HS pain
5. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
6. Gabapentin 300 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Acetaminophen 1000 mg PO Q8H
10. Hydrocortisone Oint 2.5% 1 Appl TP BID
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. Morphine SR (MS ___ 15 mg PO Q12H
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
15. Senna 2 TAB PO BID
16. Docusate Sodium 100 mg PO BID
17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 60 mg SC Q12H
5. Gabapentin 300 mg PO TID
6. Hydrocortisone Oint 2.5% 1 Appl TP BID
7. Ibuprofen 600 mg PO Q6H:PRN pain
8. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. Senna 2 TAB PO BID
14. TraMADOL (Ultram) 50 mg PO HS pain
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
16. Polyethylene Glycol 17 g PO Q12H constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth once
to twice daily Disp #*600 Gram Refills:*3
17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC
18. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
chemotherapy-induced vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Metastatic breast cancer on chemotherapy with abdominal pain,
nausea, vomiting.
COMPARISON: CT abdomen and pelvis and CT Chest from ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases
through the abdomen and pelvis after the administration of IV contrast.
Multiplanar reformatted images were prepared and reviewed.
FINDINGS:
CT ABDOMEN WITH IV CONTRAST:
The visualized lung bases again demonstrate innumerable pulmonary nodules as
well as necrotic left breast mass. The patient is status post right
mastectomy.
The liver, gallbladder, spleen, bilateral adrenal glands, pancreas, stomach,
and visualized loops of small large bowel are within normal limits. Bilateral
kidneys are normal with no evidence of hydronephrosis or stones. The appendix
is not clearly visualized but there are no secondary signs of appendicitis.
There is no free fluid or free air. There is no mesenteric or retroperitoneal
lymphadenopathy. Abdominal aorta is normal in caliber. There is no free air
or free fluid.
CT PELVIS WITH IV CONTRAST:
The uterus appears within normal limits with an IUD in place. The rectum,
sigmoid colon, and bladder appear unremarkable. There is a small amount of
free fluid, likely physiologic.
OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy. Mild diffuse body anasarca is again noted.
Subcutaneous gas is noted in the anterior subcutaneous tissues, likely from
injections.
IMPRESSION:
1. No acute abdominal or pelvic process.
2. Visualized lung bases again demonstrate innumerable pulmonary nodules as
well as a necrotic left breast mass.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Vomiting, Fever
Diagnosed with NAUSEA WITH VOMITING, DIARRHEA
temperature: 97.9
heartrate: 110.0
resprate: 20.0
o2sat: 99.0
sbp: 169.0
dbp: 99.0
level of pain: 7
level of acuity: 3.0 | ___ with history of triple negative metastatic breast cancer
treated with palliative chemo (eribulin C1D8 as of ___,
DM1 c/b gastroparesis presenting with acute onset abdominal
pain, subjective fevers/ chills, vomiting and diarrhea. Abd CT
scan
was unremarkable for acute intraabdominal process. She did
initially have hypokalemia which improved with supplementation.
She was also given intravenous fluids and her glucosuria and
ketonuria also resolved. Her symptoms of nausea, vomiting and
diarrhea as well as abdominal pain had resolved as of the
morning after her adssion.
She was able to tolerate a diet and felt improved however, she
was unable to have a bowel movement. As a result, her bowel
regimen was advanced and she responded to miralax which she was
given at time of discharge.
Otherwise, she was continued on her home medication regimen
including her insulin, enoxaparin.
She was confirmed full code at admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year-old man with PMH HCV cirrhosis and HCC
s/p DDLT ___ who presented to the ED with ~3 weeks of
progressive worsening DOE and cough. He was seen in the ED ___
with negative TTE and CXR. Subsequently followed up in
transplant
clinic ___ and prescribed a course of augmentin for possible
URI.
He describes significant dyspnea with mild exertion such as
walking to the bathroom, generally not at rest. He mostly
notices
the cough at night, while laying completely flat, and reports
lower R sided chest/abdominal pain when he coughs. States
codeine
prescribed outpatient did not help, but oxycodone helps him to
get some sleep. Denies fever/chills, chest pain, palpitations,
congestion, rhinorrhea, orthopnea, PND, lower extremity edema,
or
prior history of blood clots.
ED Course: O2 sat 93-100% on RA, flu negative, CXR without acute
process. Evaluated by GI fellow who recommended empiric
treatment
for PE given creatinine 2.4. Started on heparin gtt and admitted
with plan for V/Q scan.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
- HCV (genotype 1 and 2), now s/p SVR with sofosbuvir,
simeprevir and ribavirin in ___
- Cirrhosis ___ class B)
[+] HE
[+] EV ___, 3 cords of small EVs not amenable to banding
s/p scarring from prior banding)
[+] Refractory ascites, now s/p TIPS (___)
- Portal hypertension (with pancytopenia, splenomegaly), s/p
TIPS (___)
- Depression
- Reflux esophagitis
- Squamous cell carcinoma of the penis
- History of compartment syndrome R arm
- History of multiple orthopedic surgeries
Social History:
___
Family History:
No family history of liver disease.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: ___ 0017 Temp: 98.0 PO BP: 138/77 HR: 82 RR: 18 O2
sat: 96% O2 delivery: RA Dyspnea: 6 RASS: 0 Pain Score: ___
General: Alert, oriented, semi-frequent coughing
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Well healing surgical scar from liver txplant. Soft,
non-tender, non-distended, bowel sounds present, no
organomegaly.
Umbilical hernia
Ext: Warm, well perfused, no ___ edema
Skin: Warm, dry, seborrheic keratosis on back
Neuro: Alert and oriented, face symmetric, moves all extremities
purposefully
ACCESS: R chest POC
========================
DISCHARGE PHYSICAL EXAM
========================
Pertinent Results:
=========================
ADMISSION LAB RESULTS
=========================
___ 07:30AM BLOOD WBC-5.0 RBC-3.38* Hgb-10.2* Hct-30.5*
MCV-90 MCH-30.2 MCHC-33.4 RDW-17.0* RDWSD-56.0* Plt ___
___ 07:30AM BLOOD Neuts-72.2* Lymphs-6.4* Monos-9.6
Eos-10.6* Baso-0.4 Im ___ AbsNeut-3.63 AbsLymp-0.32*
AbsMono-0.48 AbsEos-0.53 AbsBaso-0.02
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD UreaN-30* Creat-2.4* Na-141 K-4.3 Cl-105
HCO3-20* AnGap-16
___ 07:30AM BLOOD ALT-15 AST-8 AlkPhos-256* TotBili-0.8
___ 08:15PM BLOOD proBNP-752*
___ 08:15PM BLOOD cTropnT-0.01
___ 07:30AM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.8 Mg-1.1*
___ 07:30AM BLOOD tacroFK-13.1
___ 08:31PM BLOOD Lactate-0.4*
======================
DISCHARGE LAB RESULTS
======================
___ 05:30AM BLOOD WBC-4.3 RBC-3.01* Hgb-9.1* Hct-27.5*
MCV-91 MCH-30.2 MCHC-33.1 RDW-16.8* RDWSD-56.2* Plt ___
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD Glucose-104* UreaN-24* Creat-2.3* Na-136
K-4.5 Cl-104 HCO3-23 AnGap-9*
___ 05:30AM BLOOD ALT-14 AST-9 LD(LDH)-153 AlkPhos-394*
TotBili-0.7
___ 05:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.8 Mg-1.8
___ 05:30AM BLOOD tacroFK-12.8
IMAGING AND REPORTS
======================
CHEST X-RAY ___
IMPRESSION:
No acute cardiopulmonary process.
LUNG VQ SCAN ___
IMPRESSION: Low likelihood ratio for recent pulmonary
thromboembolic disease.
RUQ ULTRASOUND ___
IMPRESSION:
1. Patent hepatic vasculature. The right hepatic artery is not
well assessed. Waveform for the main hepatic artery appears
slightly more blunted compared to prior. Main portal vein
demonstrates mild turbulent flow with velocity of 90.8
centimeter/second, previously 61.4 centimeter/second.
2. There is an echogenic linear structure in the IVC which
likely represents anastomosis but clot cannot be completelyt
excluded. A CTA multiphasic liver can be considered.
3. Splenomegaly.
CHEST CT WITHOUT CONTRAST ___
IMPRESSION:
1. No acute pulmonary parenchymal findings.
2. 1.3 cm right adrenal nodule, new compared to MRI of the
liver from ___, possibly representing focal
hemorrhage given short interval appearance. Attention on
follow-up imaging is recommended.
RUQUS ___
IMPRESSION:
1. Patent transplant hepatic vasculature.
2. Splenomegaly.
TTE ___: (with bubble study)
No e/o right to left shunt.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea// pna? pnx?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates at the cavoatrial junction, without
evidence of pneumothorax. No focal consolidation, pleural effusion, or
evidence of pneumothorax is seen. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old man with liver transplant, persistent dyspnea// Eval
liver transplant
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: None.
FINDINGS:
Liver echotexture is normal. There is no evidence of focal liver lesions or
biliary dilatation.
CHD: 6 mm
There is no ascites, right pleural effusion, or sub- or ___ fluid
collections/hematomas. There are prominent periportal lymph nodes measuring
up to 1.8 x 0.9 x 1.0 cm.
The spleen has normal echotexture.
Spleen length: 16.3 cm
DOPPLER: The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic velocity in the main hepatic artery is 46.5 cm/s, which appears
slightly more blunted compared to prior when it measured 97.6 cm/s. The right
hepatic artery is not well assessed. Appropriate arterial waveforms are seen
in the the left hepatic artery with resistive indices of 0.72, respectively.
The main portal vein demonstrates slight turbulent flow with velocity of 90.8
centimeter/second, previously 61.4 centimeter/second. 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. Patent hepatic vasculature. The right hepatic artery is not well assessed.
Waveform for the main hepatic artery appears slightly more blunted compared to
prior. Main portal vein demonstrates mild turbulent flow with velocity of
90.8 centimeter/second, previously 61.4 centimeter/second.
2. There is an echogenic linear structure in the IVC which likely represents
anastomosis but clot cannot be completelyt excluded. A CTA multiphasic liver
can be considered.
3. Splenomegaly.
NOTIFICATION: The findings were discussed with ___. ___. by ___,
M.D. on the telephone on ___ at 9:39 am, 10 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year-old man with PMH HCV cirrhosis and HCC s/p DDLT ___
who presented to the ED with 3 weeks of progressive worsening DOE and cough
of unclear etiology. Infectious workup negative, VQ scan low likelihood for
PE. Other possibility would be tacrolimus pneumonitis// pneumonitis? edema?
TECHNIQUE: MDCT axial images of the chest were obtained without
administration of intravenous contrast. Coronal and sagittal reformations
were performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 16.0 mGy (Body) DLP = 636.0
mGy-cm.
Total DLP (Body) = 636 mGy-cm.
COMPARISON: CT of the chest from ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The visualized inferior thyroid
gland is unremarkable. There is no supraclavicular or axillary
lymphadenopathy.
UPPER ABDOMEN: This study is not tailored for subdiaphragmatic evaluation.
The patient is status post liver transplant. An Amplatzer plug is seen at the
level of the pancreatic neck. The spleen is enlarged, measuring 15 cm in AP
dimension. There is a 1.3 cm right adrenal nodule, new compared to MRI of the
liver from ___, possibly representing focal hemorrhage given short
interval appearance. There is a 3 mm nonobstructing stone in the upper pole
of the left kidney. There upper abdominal varices.
MEDIASTINUM: There is no mediastinal lymphadenopathy.
HILA: There is no hilar lymphadenopathy within limitations of a noncontrast
study. Small calcified left hilar lymph nodes suggest sequelae of prior
granulomatous disease.
HEART and PERICARDIUM: Heart size is normal. There is no pericardial
effusion.
PLEURA: There is no pleural effusion.
LUNG:
1. PARENCHYMA: There is mild linear subsegmental atelectasis and peripheral
reticulation in the right lower lobe. Lungs are otherwise clear, without
parenchymal opacities. There is no pulmonary mass or suspicious nodules.
2. AIRWAYS: Central airways are patent.
3. VESSELS: The thoracic aorta and main pulmonary artery are normal in
caliber. There is a port in the right chest wall with catheter terminating at
the cavoatrial junction.
CHEST CAGE: There is no suspicious osseous lesion or acute fracture. There
are mild degenerative changes of the thoracic spine.
IMPRESSION:
1. No acute pulmonary parenchymal findings.
2. 1.3 cm right adrenal nodule, new compared to MRI of the liver from ___, possibly representing focal hemorrhage given short interval
appearance. Attention on follow-up imaging is recommended.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with recent liver transplant// Eval liver
transplant
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Doppler ultrasound ___
FINDINGS:
LIVER: The transplant hepatic parenchyma is within normal limits. The contour
of the liver is smooth. There is no focal liver mass. Trace perihepatic fluid
is again noted. A small periportal lymph node is again incidentally noted
measuring 1.4 cm. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 6 mm
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 16.2 cm
DOPPLER EXAMINATION: The main, right and left portal veins are patent with
hepatopetal flow. The hepatic veins and IVC are patent. Arterial waveforms
with sharp upstrokes are seen in the main, right and left hepatic arteries.
Resistive indices of the arteries measure 0.62, 0.51 and 0.63 in the main,
right and left hepatic arteries respectively. Peak systolic flow in the main
hepatic artery measures 89 cm/sec.
IMPRESSION:
1. Patent transplant hepatic vasculature.
2. Splenomegaly.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.1
heartrate: 74.0
resprate: 17.0
o2sat: 100.0
sbp: 122.0
dbp: 72.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ yo man with PMH of HCV cirrhosis and
hepatocellular carcinoma s/p DDLT ___ who presented to the
emergency room with 3 weeks of progressive dyspnea on exertion
and cough. Infectious work-up, V/Q scan, chest CT, and TTE with
bubble study were all unremarkable. We suspected dyspnea was due
to deconditioning from recent liver transplant, as well as
potentially with a component of post-viral subacute cough.
# Subacute Dyspnea, Cough
Patient underwent liver transplant approximately one month prior
to this admission. One week post-transplant, he developed
worsening dyspnea and cough. He presented to the ED in early
___ (prior to this admission), where TTE and CXR were
negative. He was seen on clinic and started on Augmentin. He
continued to be dyspneic with minimal activity, and presented
again to the ED. Due to concern for PE, he was started on
empiric heparin and admitted for further workup. A subsequent VQ
scan was done (given Cr 2.4) but showed low probability of PE,
so heparin was discontinued. He then underwent chest CT, but
this was unremarkable. TTE with bubble study was normal.
Infectious workup was negative, including respiratory viral
panel (Ab negative, Cx still pending). Amb SpO2 were 98% on RA.
Overall, his dyspnea was thought to be due to deconditioning
from his recent liver transplant, with potentially a component
of post-viral vs. post-nasal drip subacute cough. He was
prescribed anti-tussive medications and intranasal fluticasone.
If his cough persists, could consider Pulmonology follow up as
an outpatient.
# Chronic kidney disease
The patient's postoperative course following transplant was
complicated by ___ requiring CRRT. At that time he was
discharged with a creatinine of 2.1 (from pre-operation baseline
of about 1). On this admission, his creatinine was 2.4. He was
given 1 liter of IV fluids with subsequent improvement. His Cr
at discharge was 2.2-2.4 which is likely reflective of his new
baseline.
# HCV/___ s/p DDLT ___
# Deconditioning
Patient was discharged home after complicated ___
hospital course. Per patient's wife, she felt that he should
have gone to a rehab facility but did not qualify per ___. The
patient's major concerns post-transplant were dyspnea and
feeling deconditioned and unable to perform many activities at
home. ___ was consulted this admission and recommended home with
outpatient ___. Otherwise, a RUQUS on admission revealed elevated
resistive indices post-transplant. A repeat ultrasound was
performed a few days later and showed peak systolic flow
89cm/sec, with overall patent transplant hepatic vasculature. He
was maintained on his immunosuppression regimen of MMF,
prednisone and tacrolimus. His tacro level at discharge was
12.8, with an decreased Tacrolimus dose of 1.5mg BID.
Prophylaxis of fluconazole, bactrim and valganciclovir were
continued. He should continue to have close follow up with
Transplant Hepatology.
# Hypomagnesemia
Patient had outpatient magnesium level of 1.1. He was given
Magnesium Oxide 400 mg PO/NG BID and discharge Mg was 1.8. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief,
Mr. ___ is a ___ with history of decompensated HCV
cirrhosis (Childs ___ Class B), complicated by encephalopathy,
portal hypertension with esophageal varices and gastropathy,
GAVE, being worked up for transplant who presents with abdominal
pain.
___ has a recent admission ___ for lightheadedness, found
to have hgb 6.5, no overt bleeding but underwent EGD, GAVE
treated with APC, started on iron supplementation. ___ underwent
repeat EGD on ___ which showed medium sized varices without
high risk features, esophageal candidiasis, and angioectasias
treated with thermal therapy. ___ has not started fluconazole
because his instructions were to decrease nightly seroquel to 50
(from 400mg) while on fluconazole and ___ did not have any 50mg
tablets.
On ___ ___ started to have some lower abdominal discomfort rated
___ that ___ attributed to constipation, took some extra
lactulose and stooled (not black or bloody) and passed a lot of
gas which relieved the pain. The following day ___ developed ___
RUQ pain only noticeable when ___ presses on the RUQ, coughs, or
moves around. No changes in bowel movements, no fevers, nausea,
vomiting, or changes in color of stools or urine. Wife called
the liver clinic and ___ was referred to the ED for admission.
Of note, ___ had an abdominal MRI ___ which showed 4 lesions
that meet criteria for diagnosis of HCC (the largest is 2x2cm),
and one smaller lesion that does not (8mm). These findings have
not yet been discussed with the patient.
In the ED initial vitals were: 99.6 72 131/68 18 100% RA
- Labs were significant for Hgb 10.2 (10.4 2d prior), plt 35
(below baseline, INR 1.3, Cr 2.4 (about baseline), tbil 2.4,
(from 1.3 2 days ago), UA negative for infection. US showed
patent vasculature, no fluid to tap.
- Patient was given no medications.
Vitals prior to transfer were:98.5 64 118/73 16 100% RA
On the floor, patient has ___ RUQ pain only with palpation of
his upper abdomen. ___ is otherwise comfortable.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HCV cirrhosis diagnosed in ___, complicated by hepatic
encephalopathy, portal hypertension, varices, portal
hypertensive gastropathy, hypernatremia
- history of melena in setting of multiple esophageal varices
(grades I to 3) and possible duodenal varix, as well as portal
hypertensive gastropathy and GAVE
- HCV genotype 1b s/p relapse after interferon/Ribavirin x8-9
months years ago
- Exophytic liver mass found during ___ admission, due for 3
month f/u ___
- Neutropenia attributed to splenic sequestration
- Bipolar Disorder
- Chronic Kidney Disease secondary to lithium
- Hypertension
Social History:
___
Family History:
No family history of malignancy
Physical Exam:
Admission physical exam:
VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA
GENERAL: well appearing middle aged gentleman, well-groomed, in
no distress
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent
nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no
gallops, or rubs
LUNG: clear to auscultation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain
localizes to liver edge on inspiration as palpate. No
rebound/guarding, +splenomegaly.
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm without rashes, has scattered spider angiomata and
palmar erythema
Discharge physical exam:
VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA
GENERAL: well appearing middle aged gentleman, well-groomed, in
no distress
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent
nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no
gallops, or rubs
LUNG: clear to auscultation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain
localizes to liver edge on inspiration as palpate. No
rebound/guarding, +splenomegaly.
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm without rashes, has scattered spider angiomata and
palmar erythema
Pertinent Results:
Admission labs:
___ 07:41PM BLOOD WBC-4.4# RBC-3.28* Hgb-10.2* Hct-32.5*
MCV-99* MCH-31.1 MCHC-31.3 RDW-20.5* Plt Ct-35*
___ 07:41PM BLOOD Neuts-68.1 ___ Monos-9.3 Eos-2.1
Baso-0.5
___ 08:01PM BLOOD ___ PTT-31.8 ___
___ 07:41PM BLOOD Glucose-93 UreaN-30* Creat-2.4* Na-138
K-4.7 Cl-110* HCO3-23 AnGap-10
___ 07:41PM BLOOD ALT-42* AST-68* AlkPhos-215* TotBili-2.4*
___ 07:41PM BLOOD Albumin-3.2*
___ 07:49PM BLOOD Lactate-2.2*
Discharge labs:
___ 08:28AM BLOOD WBC-3.2* RBC-3.18* Hgb-9.4* Hct-31.2*
MCV-98 MCH-29.7 MCHC-30.2* RDW-20.5* Plt Ct-36*
___ 08:28AM BLOOD Plt Ct-36*
___ 08:28AM BLOOD Glucose-146* UreaN-29* Creat-2.3* Na-138
K-4.1 Cl-109* HCO3-22 AnGap-11
___ 08:28AM BLOOD ALT-40 AST-61* AlkPhos-185* TotBili-2.1*
___ 08:28AM BLOOD Calcium-8.6 Phos-3.7 ___ EGD
Medium sized varices without high risk features at the distal
esophagus
Esophageal candidiasis
Angioectasias in the antrum (thermal therapy)
Otherwise normal EGD to third part of the duodenum
___ Liver US wet read
RUQ US: nothing acute (vasculature patent, gallbladder
decompressed, tumors not seen due to coarse echotexture, no
fluid to tap, some gallbladder thickening explained by
cirrhosis)
___ CT chest
1. Assessment of the chest demonstrated no definitive evidence
of metastatic disease. Mild emphysema and centrilobular nodules
are most likely consistent with respiratory bronchiolitis,
please correlate clinically.
2. Several mediastinal lymph nodes, some of them borderline that
should be reassessed in three months for documentation of
stability.
3. Potential anemia.
4. Paracardiac lymph nodes, borderline as well and should be
reassessed at the same time.
5. Stigmata of cirrhosis, partially imaged, will be assessed in
details as part of the MRI of the abdomen and the corresponding
report will be issued.
___ MRI abdomen
IMPRESSION:
1. Three OPTN-5a lesions within segments II and VI, and one
OPTN-5b lesion within segment IVb.
2. 8 mm arterially enhancing lesion within segment VII, not
meeting OPTN-5 criteria.
3. Hepatic cirrhosis with multiple regenerative nodules.
4. Massive splenomegaly with perisplenic and perigastric varices
reflecting chronic portal hypertension.
5. Small amount of perihepatic and perisplenic ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO EVERY OTHER DAY
2. Lactulose 30 mL PO TID
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. QUEtiapine Fumarate 400 mg PO QHS
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Sucralfate 1 gm PO QID
9. Ferrous Sulfate 325 mg PO BID
10. Fluconazole 200 mg PO Q24H
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Lactulose 30 mL PO TID
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. QUEtiapine Fumarate 400 mg PO QHS
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Sucralfate 1 gm PO QID
10. Nystatin Oral Suspension 5 mL PO QID Duration: 10 Days
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp
#*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
HCV cirrhosis
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: ___ w/HCV cirrhosis c/b ___ presents w/1 day of RUQ pain.
Tenderness to palpation in RUQ. // Evaluate for cholecystitis, portal vein
thrombosis, tumor necrosis/bleed. Please also evaluate for fluid pocket
amenable to paracentesis (did not see any on bedside US)
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI abdomen dated ___
FINDINGS:
LIVER: The liver is nodular with coarsened echotexture consistent with
history of cirrhosis. The liver lesions detected on the MRI are not as well
visualized on the ultrasound related to the coarsened echotexture. 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 decompressed without evidence of stones. There
is gallbladder wall thickening related to chronic cirrhosis. Sonographic
___ sign was negative.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 23.9 cm. Note is again made of
perisplenic varices
IMPRESSION:
1. Cirrhotic liver. Liver lesions were better evaluated on MR of ___.
2. Patent hepatic vasculature. No ascites
3. Splenomegaly and varices consistent with sequela of portal hypertension
4. No evidence of cholecystitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with SPRAIN OF KNEE & LEG NOS, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT
temperature: 99.6
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 68.0
level of pain: 6
level of acuity: 3.0 | ___ with history of decompensated HCV cirrhosis (___
Class B), complicated by encephalopathy, portal hypertension
with esophageal varices and gastropathy, GAVE, being worked up
for transplant who presents with abdominal pain. His abdominal
resolved quickly on the floor and ___ was anxious for same day
discharge home.
# Abdominal pain: Patient appears to have a tender liver edge,
which may have bene related to a more inferior liver lesion. ___
had no signs or symptoms of cholecystitis, no rebound tenderness
or peritoneal signs. Not constipated. US was negative for clot.
Discussed with liver team, did serial abdominal exams, trended
MELD labs, and followe up blood and urine cultures.
# Esophageal candidiasis:
Was prescribed fluconazole previously but never started course
because ___ was concerned about decreasing his seroquel dosing
and risk of a manic episode. ___ was switched to nystatin swish
and swallow for 10 day course, with GI followup.
# liver lesions: New MRI findings (liver lesions) discussed with
patient. Did not yet discuss with him whether this will impact
his transplant. Tumor board meets ___. After this will be
discussed with patient, wife, and hepatology.
# HCV cirrhosis: undergoing transplant work up, patient of Dr.
___ is Childs B, with diuretic-controlled ascites,
varices, and history of encephalopathy. TrendED MELD labs daily,
continueD furosemide and spironolactone for ascites. Continue
lactulose and rifaxamin for h/o encephalopathy.
# GAVE/Varices: No signs of active bleeding. Continued
sucralfate, nadolol and PPI, and iron supplementation.
# Thrombocytopenia: Worse than baseline possibly related to
massive splenomegaly (sequestration) and decreased thrombopoetin
production. Trended daily. Held heparin, used pneumoboots while
platelets <50K .
# Bipolar disorder: Continued seroquel. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - Oral and IV Dye
Attending: ___.
Chief Complaint:
Chest pain/discomfort
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures were performed during
this hospitalization.
History of Present Illness:
___ male past medical history of CAD s/p CABG and 5x
stents, hyperlipidemia, hypertension, stroke, atrial
fibrillation (not on A/C), tissue aortic valve replacement
resenting complaining of chest discomfort. Patient states that
his pain began 2 days ago and felt like gas pain. He states the
pain was constant and associated with nausea. He also endorses a
feeling as though his heart was racing as well as
lightheadedness.
Patient was found to be tachycardic at his primary care
physician's office today and was referred to ___.
Patient found to be in atrial flutter with rates in 130s. Given
concomitant chest pain and elevated troponin I to 0.36, he was
given 50mg IV diltiazem with subsequent improvement in rates to
60-70s. He was also given morphine and nitroglycerin SL with
resolution of his chest pain. He was given a full dose aspirin
and started on heparin gtt, then transferred here for further
evaluation and consideration for LHC.
In the ED, initial vitals were: T 97.5, HR 79, BP 142/71, RR 15,
O2Sat 100%RA
- Exam notable for: CTAB, RRR, abdomen benign
- Labs notable for: TropT 0.03, Cr 1.5, Hgb 10.9, WBC 7.2
- While in the ED, the patient's heart rate increased again to
126bpm sustained so he was given an additional 20mg IV diltiazem
and 30mg PO.
- Vitals prior to transfer: HR 63, 114/59, RR 13, O2Sat 94%RA
On arrival to the floor, the patient denies any ongoing chest
pain. Also denies fevers, chills, cough, shortness of breath,
leg swelling or tenderness or any recent travel.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- CAD s/p CABG and 5x stents
- Hyperlipidemia
- Hypertension
- H/o stroke
- H/o atrial fibrillation (not on anticoagulation)
- S/p aortic valve replacement (tissue)
- PAD
- GERD
Social History:
___
Family History:
-Father died at ___
-Mother died at ___ is unaware of her medical history
-Brothers with coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 98.5, 98/64 (98-125/64-59), 102 (82-102), 16, 97%
RA
Weight: 94.9 kg
General: Alert, oriented, no acute distress, walking around
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: Supple. JVP flat (visible only with hepatic pressure).
CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, trace to no edema
DISCHARGE PHYSICAL EXAM:
========================
VITALS: afebrile, BP ___, HR ___, RR ___, O2
100% RA
GENERAL: Alert, oriented, no acute distress, walking around
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple. JVP flat (visible only with hepatic pressure).
HEART: Irregularly irregular. Normal S1+S2, soft systolic
murmur.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended
EXT: Warm, well perfused, trace to no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 11:15PM BLOOD WBC-7.2 RBC-3.64* Hgb-10.9* Hct-33.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-14.4 RDWSD-48.5* Plt ___
___ 11:15PM BLOOD Neuts-56.3 ___ Monos-9.8 Eos-3.3
Baso-1.4* Im ___ AbsNeut-4.07 AbsLymp-2.07 AbsMono-0.71
AbsEos-0.24 AbsBaso-0.10*
___ 11:15PM BLOOD ___ PTT-67.6* ___
___ 11:15PM BLOOD Glucose-85 UreaN-19 Creat-1.5* Na-141
K-4.3 Cl-107 HCO3-22 AnGap-16
___ 06:15AM BLOOD CK(CPK)-51
___ 11:15PM BLOOD CK-MB-3
___ 11:15PM BLOOD cTropnT-0.03*
___ 06:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 Cholest-158
___ 06:15AM BLOOD Triglyc-182* HDL-26 CHOL/HD-6.1
LDLcalc-96 LDLmeas-108
MICROBIOLOGY:
=============
NONE
IMAGING:
========
CXR (___):
FINDINGS:
There is dense retrocardiac opacification and mild chronic lung
disease. The remainder of the lungs are clear. No pleural
effusion or pneumothorax. Heart size is normal. Median
sternotomy wires are midline and intact. Surgical clips project
over the mediastinum. A presumed aortic valve replacement is
noted.
IMPRESSION:
1.Dense retrocardiac opacity likely reflecting atelectasis in
the absence of infectious symptoms.
2. Mild chronic lung disease.
LABS ON DISCHARGE:
==================
___ 04:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.4
___ 04:50AM BLOOD ALT-12 AST-16 LD(LDH)-222 AlkPhos-82
TotBili-0.4
___ 04:50AM BLOOD Glucose-87 UreaN-23* Creat-1.7* Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
___ 04:50AM BLOOD ___ PTT-50.8* ___
___ 04:50AM BLOOD WBC-7.2 RBC-3.59* Hgb-10.7* Hct-33.5*
MCV-93 MCH-29.8 MCHC-31.9* RDW-14.3 RDWSD-48.9* Plt ___
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: ___ year old man with Afib/Aflutter// baseline CXR prior to
initiation of amiodarone
TECHNIQUE: Frontal lateral views of the chest
COMPARISON: None.
FINDINGS:
There is dense retrocardiac opacification and mild chronic lung disease. The
remainder of the lungs are clear. No pleural effusion or pneumothorax. Heart
size is normal. Median sternotomy wires are midline and intact. Surgical
clips project over the mediastinum. A presumed aortic valve replacement is
noted.
IMPRESSION:
1. Dense retrocardiac opacity likely reflecting atelectasis in the absence of
infectious symptoms.
2. Mild chronic lung disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 97.5
heartrate: 79.0
resprate: 15.0
o2sat: 100.0
sbp: 142.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old man with CAD s/p CABG, cardiac
stents, HLD, HTN, CVA, and history of A fib who presented with
chest pressure/epigastric pain secondary to Afib/flutter with
RVR. At first there was concern for ACS but his trops trended
down quickly and he had recent normal pharm nuc stress test in
___ at ___. He had on-going chest pain with afib
RVR/aflutter with better response to diltiazem than metoprolol.
Because of this he was switched from metoprolol to diltiazem.
The patient spontaneously converted to normal sinus rhythm in AM
of ___ prior to TEE cardioversion, and patient was discharged
on amiodarone.
#HISTORY OF ATRIAL FIBRILLATION WITH NEW ATRIAL FLUTTER, RVR:
patient presented with rapid rates in ED. Initially controlled
with IV metop and dilt, followed by increased dose of PO metop
(home dose 50XL, given 75mg XL). Broke through with episodes of
RVR, so switched to PO diltiazem with rates decreasing to
___. Of note, the patient is not on anticoagulation prior to
admission because AFib improved after valve replacement and
because of a GI bleed requiring ICU about ___ years ago (while on
warfarin) and smaller amounts of blood in stool since. Patient's
home clopidogrel for ___ PAD/stents was held on admission, and
he was started on a heparin drip which was continued until
apixiban started. Given the patient's persistent Afib/Aflutter,
he was scheduled to undergo a TEE cardioversion in AM of ___.
The patient spontaneously converted to sinus rhythm in AM of
___, and TEE cardioversion was canceled. Patient was started on
amiodarone 200 mg 3 times daily for 1 week, then twice daily for
1 week, then once daily ongoing. Baseline CXR on ___
demonstrated dense retrocardiac opacity, likely reflecting
atelectasis in the absence of infectious symptoms, and mild
chronic lung disease. Baseline LFTs on ___: ALT 12, AST 16. TSH
pending at time of discharge. He was discharged on long-acting
diltiazem 120 mg PO daily, in addition to apixaban 2.5 mg PO BID
for anticoagulation.
#NSTEMI/DEMAND ISCHEMIA: patient has a known history of CAD s/p
CABG and multiple stents. Mild troponin elevation in the setting
of sustained tachycardia (0.03 to 0.02) in setting of CKD
(creatinine 1.4 in ___ in ___ records). Pharm stress
test canceled as patient recently received one in ___. He
was continued on home ASA, home Imdur.
CHRONIC/STABLE ISSUES:
======================
#CKD: Baseline Cr appears to be 1.3-1.7 from ___ records from
___ and the ___. Cr remained at baseline during
hospitalization.
#PVD s/p bilateral lower extremity stents: significant PAD,
symptomatic. Per patient's wife, patient has lower extremity
stents placed many years ago. He was continued on home
pentoxyifylline, and clopidogrel was held at discharge in favor
of continuing ASA and apixaban as above.
#HYPERTENSION: Continued imdur, metop and lisinopril.
#HYPERLIPIDEMIA: Patient has a reported allergy to statins. He
was continued on ezetimibe.
#GERD: Continued home Protonix. |
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 falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man with CAD s/p CABG (at age
___, hypertension, hyperlipidemia, vascular dementia, chronic
orthostatic hypotension who presented to the ED on ___t home and increasing weakness. ___
patient was in the bathroom and had one unwitness fall against
the wall. His wife was nearby and noted that he did not lose
consiousness, but there was a question of head trauma. He was
propped against the door so it was difficult for his wife to get
him out of the bathroom and she had to call her son to help.
Later the same day, he had another fall that appears to be
mechanical in nature, which he sustained while he was trying to
sit in a chair and missed the seat. There was no loss of
consciousness or head trauma associated with that fall. Given
his advanced dementia, he is unable to clarify if there were any
prodromal symptoms leading up to either fall. The following day
___, he was at an ophthalmology appointment and was noted to
be very weak in the lower extremities and was unable to stand,
requiring a wheelchair. He was seen promptly by his PCP ___.
___ suggested he go to the ED for evaluation.
In the ED, initial vitals were 98.6 79 119/77 18 96% on RA.
Exam was notable for baseline alertness and orientation to self
only. There was also concern for possible nasolabial fold
flattening. Labs were unremarkable with the exception of a
grossly positive urinalysis. Given this finding and his new
weakenss, a neurology consult was obtained, and they felt his
exam was unremarkable for focal findings to suggest stroke and
instead suggested that a urinary tract infection may explain his
new weakness. A non contrast head CT and chest x-ray were both
unremarkable. He was started on ceftriaxone (day 1 = ___
and sent to the floor for further management.
Overnight, patient felt well and had no specific complaints. He
denied any pain, or weakness that he could appreciate, though
his history is limited by his severe dementia. In discussion
with Dr. ___ morning, he noted that the patient may have
had increased urinary frequency recently that would fit with the
diagnosis of UTI. On review of systems, he denies nausea,
vomiting, abdominal pain, back pain, headache, chest pain, or
shortness of breath.
Past Medical History:
- CAD s/p CABG (___)
- Hypertension
- Hyperlipidemia
- Vascular dementia
- AAA s/p repair
- Postural hypotension
- Osteoarthritis s/p bilateral total hip replacement
- Age related macular degeneration
- Hypothyroidism
- Gout
- History of bladder stone
- BPH
Social History:
___
Family History:
MI (maternal uncle at age ___. No known stroke or neurologic
disease. Father was healthy, died of old age at ___. Mother died
when he was age ___, unknown cause.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.3 178/86 72 16 98% on RA
GENERAL: well appearing elderly male in NAD laying flat
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD
LUNGS: bibasilar crackles
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, please see
neuro note for complete exam
DISCHARGE PHYSICAL EXAM:
VS: 97.3/98.4 146/83 71 18 97%RA
GENERAL: well appearing elderly male comfortably eating
breakfast
HEENT: NC/AT, left pupil asymmetric, poor vision bilaterally,
EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD
LUNGS: bibasilar crackles
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, please see
neuro note for complete exam
Pertinent Results:
Admission labs:
___ 04:50PM BLOOD WBC-10.3 RBC-4.08* Hgb-13.0* Hct-39.7*
MCV-97 MCH-31.7 MCHC-32.7 RDW-16.2* Plt ___
___ 04:50PM BLOOD Neuts-77.9* Lymphs-14.2* Monos-6.3
Eos-1.1 Baso-0.5
___ 04:50PM BLOOD ___ PTT-36.6* ___
___ 04:50PM BLOOD Glucose-128* UreaN-34* Creat-1.1 Na-142
K-4.3 Cl-106 HCO3-26 AnGap-14
Discharge Labs:
___ 09:15AM BLOOD WBC-8.8 RBC-3.85* Hgb-11.6* Hct-37.2*
MCV-97 MCH-30.1 MCHC-31.2 RDW-15.6* Plt ___
___ 08:26AM BLOOD Glucose-109* UreaN-23* Creat-1.0 Na-144
K-3.8 Cl-107 HCO3-28 AnGap-13
___ 08:26AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2
Micro:
___ urine culture pending: Enterococcus 10k-100k
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Studies:
___ CT head without contrast:
No intracranial hemorrhage or acute territorial infarction.
___ Chest x-ray (portable):
Mild bibasilar atelectasis and probable trace left pleural
effusion. Unchanged moderate size hiatal hernia.
EKG: NSR at 70, NA, NI, RBBB, TWI in 3, avF, V1-V3 without any
change from prior.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO EVERY OTHER DAY
2. Omeprazole 20 mg PO BID
3. Allopurinol ___ mg PO DAILY
4. Levothyroxine Sodium 200 mcg PO DAYS (___)
5. Finasteride 5 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO QPM
7. Quetiapine Fumarate 50 mg PO Q8H PRN agitation
8. Terazosin 1 mg PO HS
9. Dipyridamole-Aspirin 1 CAP PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Senna 1 TAB PO BID:PRN constipation
12. Metoprolol Tartrate 50 mg PO QAM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO DAILY
3. Finasteride 5 mg PO DAILY
4. Levothyroxine Sodium 200 mcg PO DAYS (___)
5. Metoprolol Tartrate 25 mg PO QPM
6. Metoprolol Tartrate 50 mg PO QAM
7. Omeprazole 20 mg PO BID
8. Quetiapine Fumarate 50 mg PO Q8H PRN agitation
9. Simvastatin 40 mg PO EVERY OTHER DAY
10. Terazosin 1 mg PO HS
11. Ampicillin 500 mg PO Q6H Duration: 7 Days
Continue through ___
RX *ampicillin 500 mg 1 capsule(s) by mouth four times a day
Disp #*24 Capsule Refills:*0
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnoses:
- Urinary tract infection
- Mechanical fall
Secondary diagnoses:
- CAD s/p CABG (___)
- Hypertension
- Hyperlipidemia
- Vascular dementia
- AAA s/p repair
- Postural hypotension
- Osteoarthritis s/p bilateral total hip replacement
- Age related macular degeneration
- Hypothyroidism
- Gout
- History of bladder stone
- BPH
Discharge Condition:
Mental Status: Confused - always. Oriented to self only.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Coronary artery disease, vascular dementia with mechanical fall.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: ___.
FINDINGS:
The patient is status post median sternotomy and CABG. Heart size remains
mildly enlarged, unchanged. Moderate size hiatal hernia is re- demonstrated.
Aortic knob calcifications are present. The mediastinal and hilar contours
are unchanged, and there is no pulmonary vascular congestion. Linear
opacities in both lung bases likely reflect subsegmental atelectasis. Minimal
blunting of the left costophrenic sulcus suggests a trace left pleural
effusion. No pneumothorax is identified.
IMPRESSION:
Mild bibasilar atelectasis and probable trace left pleural effusion.
Unchanged moderate size hiatal hernia.
Radiology Report
HISTORY: Multiple falls and change in mental status.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal, sagittal, and thin slice bone
algorithm reformats were reviewed.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large territorial
infarction. Prominent ventricles and sulci are compatible with age-related
volume loss. Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. The basal cisterns appear 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:
No intracranial hemorrhage or acute territorial infarction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ALT MS/S/P FALL
Diagnosed with URIN TRACT INFECTION NOS, ALTERED MENTAL STATUS
temperature: 98.6
heartrate: 79.0
resprate: 18.0
o2sat: 96.0
sbp: 119.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ yo male with history of CAD s/p CABG, HTN, HL, vascular
dementia, BPH, and chronic orthostatic hypotension who presents
s/p fall X2 and confusion for the past two weeks found to have a
UTI.
# Enterococcus UTI: History of possible increased urinary
frequency noted by Dr. ___ positive urinalysis, and
10k-100k enterococcus growing in culture. It is very possible
that this urinary tract infection could account for his new
weakness. He was initially started on ceftriaxone in the ED and
transitioned to ampicillin on ___ given susceptibilities. He
should continue ampicillin 500 mg PO Q6H through ___.
# Vascular dementia: Unlikely to have an acute stroke per
neurology assessment but he should continue antiplatelet therapy
with dipyridamole-aspirin. Neurology raised the possibility that
Multiple System Atrophy (MSA), Shy ___ Type could be a
unifying diagnosis. Autonomic consultation as an outpatient
might help with management. Nocturnal episodes in MSA are often
manifestations of REM sleep behavior disorder rather than
sundowning, but history is unclear here. If he has apparent
dream enactment (yelling, arm movements as though fighting) at
night that diagnosis should be considered as it is treated with
medications other than Seroquel, usually clonazepam but high
dose melatonin is also useful.
# Cervical spondylosis and myelopathy and lumbosacral
radiculopathy: Per neurology, there is no need for emergent
imaging to assess his cervical or lumbar spines for disc
disease, but this could be obtained by his primary care
physician. Treatment with a soft cervical collar could be
considered.
# Gout: Continued allopurinol.
# Hypothyroidism: Continued levothyroxine ___ through ___.
# BPH: Continued finasteride and tamsulosin.
# Hyperlipidemia: Continued simvastatin.
# Transitional:
- Emergency contact: Wife ___ who is HCP ___ or
___
- Continue ampicillin 500 mg PO Q6H through ___ for
enterococcus UTI
- Recommend neuro follow up in ___ clinic with Dr. ___
___ or Dr. ___ for evaluation for possible Multiple
System Atrophy (MSA), Shy ___ Type
- Consider soft collar for symptomatic management of cervical
spondylosis, myelopathy, lumbosacral radiculopathy |
Name: ___. Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Robitussin A-C / Clindamycin / Lipitor / latex
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
___ with h/o afib not on warfarin, HTN, TIA who presents with
diffuse abdominal pain and weakness and was referred to the ED
for rapid afib.
Pt reports she was in her usual state of health until ___
(3d ago) when she developed severe diffuse abdominal pain. She
reports it is hard to describe the quality, but it was very
intense and lasted ___. She believes she had a prior episode
of this and sought medical attention but is not sure what it was
from. She reports the pain resolved within 2hrs. She had ___
nausea but induced emesis x1 to see if it would help. Then the
next day (___), she developed L shoulder and lateral chest
pain. She reports this was less intense but lasted in the
evening ___ into ___. She reports ___ n/v/diarrhea. ___
fevers. She had brief palpitations on ___ that she did not
make much of. ___ dysuria. ___ changes in stool pattern. ___
dizziness or SOB. On ___, she noted malaise and generalized
weakness with persistence of L shoulder discomfort. She has been
eating and drinking ok. She thus, presented to her PCP ___.
She was seen in ___ clinic today where VS: BP: 100/62. Heart
Rate: 130, and irregular so referred to ED for rapid afib.
In the ED, initial vitals: 98.9 125 144/87 18
- Exam notable for: RLQ tenderness, tachy to 130s in flutter
- HR resolved to ___ s/p 1LNS
- Labs notable for: WBC 5.8 (72%N), AST/ALT 77/254, T bili 0.9,
AP 128, BUN/Cr ___, lactate 2, trop neg x2
- Imaging: CT abd with Filling defect in the distal common bile
duct with mild extrahepatic biliary ductal dilatation,
concerning for choledocholithiasis
- Consultants: ERCP called and reportedly plan for ERCP tomorrow
___ east beds though)
- Patient was given: 1L NS, 1g tylenol for pain
- Vitals prior to transfer: 98.2 59 147/71 18 98% RA
On arrival to the floor, pt reports ___ discomfort in L
shoulder and lateral chest area (previously a ___. ___ nausea,
palpitations, abdominal pain.
Past Medical History:
- HTN
- Afib, not on anticoagulation
- Rheumatic Heart Disease with moderate MR. ___ mitral stenosis
seen on echo in ___.
- TIA
- HLD
- Cervical cancer s/p TAH/BSO ___
- S/p cholecystectomy with RUQ pain after
- H/o adjustment disorder/depression
- Lung nodule
- Mild Pulmonary Hypertension
- GERD
- Left Subclavian Stenosis: Noted to have asymmetric blood
pressures (R>L) in ___ when seeing cardiology, also noted to
have a carotid bruit. Carotid U/s followed by MRA ___ identified
subclavian steal physiology with retrograde left vertebral
artery flow.
Social History:
___
Family History:
___ liver or gallbladder issues
Physical Exam:
Admission PE:
Vitals: 97.4, 116/89, 59, 98% RA
General: well-appearing elderly woman, looks younger than stated
age, nontoxic, in NAD
HEENT: MMM, ___ scleral icterus appreciated
Neck: supple, ___ LAD
CV: irregular, normal rate, ___ murmurs appreciated
Lungs: CTAB, breathing comfortably
Abdomen: soft, ND, RLQ > LLQ TTP, ___ RUQ TTP even with deep
palpation, +BS
GU: ___ foley
Ext: WWP. ___ edema
Neuro: grossly intact, attentive and appropriate
.
Discharge PE:
Vitals: afebrile, 120-140s/60-70s, 60s, 97% RA
General: well-appearing elderly woman, looks younger than stated
age, nontoxic, in NAD
Neck: supple
CV: RRR, ___ murmurs appreciated
Lungs: CTAB, breathing comfortably
Abdomen: NT, ND, soft
Ext: WWP. ___ edema
Neuro: grossly intact, attentive and appropriate
Pertinent Results:
Admission Labs:
___ 10:34AM BLOOD WBC-5.8 RBC-5.48* Hgb-15.9 Hct-47.4
MCV-87 MCH-29.1 MCHC-33.6 RDW-14.0 Plt ___
___ 10:34AM BLOOD Neuts-72.8* Lymphs-17.9* Monos-7.7
Eos-0.7 Baso-0.8
___ 10:34AM BLOOD ___ PTT-25.9 ___
___ 10:34AM BLOOD Glucose-116* UreaN-19 Creat-1.2* Na-137
K-4.6 Cl-104 HCO3-22 AnGap-16
___ 10:34AM BLOOD ALT-254* AST-77* AlkPhos-128* TotBili-0.9
___ 10:34AM BLOOD Lipase-41
___ 04:35PM BLOOD cTropnT-<0.01
___ 10:34AM BLOOD cTropnT-<0.01
___ 10:34AM BLOOD Albumin-4.2
___ 11:40AM BLOOD Lactate-2.0
.
>> IMAGING:
CT abd:
1. Filling defect in the distal common bile duct with mild
extrahepatic biliary ductal dilatation, concerning for
choledocholithiasis. An MRCP may be done for further assessment.
2. Normal appendix.
3. Perivaginal cystic structure possibly representing a
Bartholin gland cyst with adjacent fat stranding. Clinical
correlation is recommended.
.
Discharge Labs:
___ 07:01AM BLOOD WBC-6.0 RBC-4.13* Hgb-12.5 Hct-35.8*
MCV-87 MCH-30.2 MCHC-34.8 RDW-13.4 Plt ___
___ 07:10AM BLOOD Glucose-99 UreaN-20 Creat-0.9 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
___ 07:01AM BLOOD ALT-136* AST-38 AlkPhos-115* TotBili-0.9
.
>> ERCP ___:
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
The scout film was normal.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
The CBD was 15mm in diameter.
A single filling defect consistent with a large 1.5cm stone was
identified in the CBD.
The left and right hepatic ducts and all intrahepatic branches
were normal.
A biliary sphincterotomy was made with a sphincterotome. There
was ___ post-sphincterotomy bleeding.
Given the large size of the stone, a sphincteroplasty was
successfully performed using a ___ CRE balloon and
dilating up to 13.5mm.
There was a moderate self limited bleeding after the
sphincteroplasty.
Given the risk of further bleeding, lithotripsy of the large
stone was deferred. A 10mm X 60mm fully covered WallFlex metal
stent (REF ___, ___ was successfully placed for
hemostasis.
Brisk drainage of bile and contrast was noted endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
Restart ___. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H
Last day ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
6. 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:
Primary diagnosis: Choledocholithiasis, rapid atrial
fibrillation
Secondary diagnosis: hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with rapid afib, weakness. Eval for PNA // eval for PNA
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
There is mild cardiomegaly. The lungs are clear without focal consolidation or
effusion. There is no pulmonary edema. No acute osseous abnormalities
identified.
IMPRESSION:
Cardiomegaly without acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with right lower quadrant abdominal pain
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
No oral contrast was administered.
DOSE: DLP: 518.09 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL Omnipaque
COMPARISON: Abdominal pelvis CT 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 are 2 hypodensities, 1 in segment 4A (series 2, image 9), and the other
in segment 6 (series 2, image 27), statistically most likely simple cysts. The
common bile duct is dilated at 10 mm with a filling defect within the distal
common bile duct. Patient is post cholecystectomy. No intrahepatic biliary
ductal dilatation is present.
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 have bilateral tiny hypodensities, too small to
characterize, statistically most likely simple cysts. No hydronephrosis or
hydroureter.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening or fat stranding. The appendix is
normal.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal 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: The patient is post hysterectomy. Adjacent to the vagina
in the right perineal region, there is possibly a cyst with associated fat
stranding, possibly a Bartholin gland cyst.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
1. Filling defect in the distal common bile duct with mild extrahepatic
biliary ductal dilatation, concerning for choledocholithiasis. An MRCP may be
done for further assessment.
2. Normal appendix.
3. Perivaginal cystic structure possibly representing a Bartholin gland cyst
with adjacent fat stranding. Clinical correlation is recommended.
RECOMMENDATION(S): An MRCP may be done for further assessment of biliary
tree.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 4:02 ___, 5 minutes after discovery of the
findings.
Gender: F
Race: HISPANIC/LATINO - COLUMBIAN
Arrive by AMBULANCE
Chief complaint: Atrial fibrillation
Diagnosed with ATRIAL FIBRILLATION, ABDOMINAL PAIN RLQ
temperature: 98.9
heartrate: 125.0
resprate: 18.0
o2sat: nan
sbp: 144.0
dbp: 87.0
level of pain: nan
level of acuity: 2.0 | ___ with h/o afib not on warfarin, HTN, TIA who presents with
diffuse abdominal pain and weakness and was referred to the ED
for rapid afib.
.
# Choledocholithiasis: Pt presented after an episode of severe
diffuse abdominal pain 3d prior to admission. ___ significant abd
pain since with fluctuating abdominal exam - RLQ>LLQ TTP
initially and then RUQ on HD2. Given LFTs abnormalities and CT
findings concerning for filling defect in CBD, pt went for ERCP
___, which showed a large stone in the CBD. There was
self-limited bleeding during sphincterotomy so the gallstone was
unable to be removed and a stent was placed. Pt looked
clinically well throughout. LFTs downtrended. Pt had ___ evidence
of cholangitis throughout. Plan for repeat ERCP for stent
removal and lithotripsy in ___. 5d course of Cipro BID per
ERCP recs. Diet advanced without difficulty prior to discharge
on ___.
.
# L shoulder/lateral chest pain: mild and somewhat nonspecific.
ACS ruled out with serial trops. Unclear if this is related to
potential choledocholithiasis though would expect referred pain
to be in R shoulder. Could be MSK. Pain resolved during
admission.
.
# Afib: initially rapid in clinic to 130, improved to ___ with
IVF and then in the high 50-60s in sinus with PACs. CHADS score
is 4 - not on anticoagulation as pt has declined in the past. Pt
continued on Amio and ASA. Pt flipped back to rapid afib the
morning of ___ (to 110-130) so low dose PO metop started and pt
discharged on metop succinate 25mg daily. Discussed
anticoagulation with her given high CHADS score and she will
discuss further with PCP at ___.
.
# CKD: baseline Cr around 0.9-1, most recently 1.3 in ___.
1.2 on presentation, now 0.9 IVF
.
# HTN: restarted lisinopril on discharge.
# H/o TIA: cont ASA 81
.
>> Transitional issues:
# CODE STATUS: confirmed Full
# CONTACT: daughter, ___ ___
# 5day course of Cipro 500 BID per ERCP recs until ___
# Holding ASA for 4 days after ERCP to restart ___
# Started metoprolol succinate 25mg daily given pt flipped back
into rapid afib during admission.
# Discussed anticoagulation with pt and her daughter given high
CHADS score. Please continue discussions.
# Repeat ERCP in ___ for stent removal and lithotripsy of CBD
gallstone |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R leg cellulitis and R Heel Ulcer
Major Surgical or Invasive Procedure:
Bedside foot debridement
History of Present Illness:
___ with multiple medical problems including COPD, DM, PAD, NHL,
and atrial fibrillation (not anticoagulated) presenting with
right leg swelling and redness. Per report, the patient cut his
leg a few months ago which has been monitored and treated by
___. He began to experience new right heel pain with ambulation
on ___. His ___ recommended he presented to the ED when the
redness was felt to have started to increase. No report of
fevers or chills.
In the ED, initial vital signs were 97.0 85 121/61 18 97%. His
labs revealed leukocytosis to 15.6 with 88% PMNs and BUN/Cr
___. He was evaluated by the podiatry team who recommended
admission for IV antibiotics and possible OR debridement. The
wound was reported as deeply probing but not to bone. He was
given vancomycin, ciprofloxacin, and flagyl.
On the floor, his vital signs were ___, 114/50, 86, 20, 100%RA
and the borders of his leg cellulitis was demarked with a marker
Review of Systems:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
ABNORMAL LFTS ___
ANEMIA ___ - microcytic, normal iron, tsh, creat
PROSTATE CANCER - TURP ___ prostate cancer on bx
CHRONIC OBSTRUCTIVE PULMONARY DISEASE - hx tob 60pk yr
DIABETES MELLITUS ___
DIVERTICULOSIS
ERECTILE DYSFUNCTION - low testosterone
GASTROESOPHAGEAL REFLUX
HEARING LOSS - 70% B/L, uses aids
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPONATREMIA ___ - c/w SIADH
NON-HODGKIN'S LYMPHOMA ___ - rituxan
MAJOR DEPRESSION - complicated bereavement, chronically anxious
OSTEOARTHRITIS - knee
PERIPHERAL NEUROPATHY ___ - spinal stenosis moderate/severe,
and polyradiculopathies mild/moderate EMG
SECOND DEGREE ATRIOVENTRICULAR BLOCK - type I
SHOULDER PAIN - rotator cuff tear ___ MRI
SPINAL STENOSIS - ___, severe L4-5 spinal stenosis
SYNCOPE - hx distant with needles, recent with needle pain
___
ULCERATIVE COLITIS
URINARY INCONTINENCE ___ - s/p TURP
VENOUS STASIS
CATARACT ___ - right IOL
GLAUCOMA ___ - open angle iridectomy
DECUBITUS BUTTOCK UL
peripheral arterial disease
Atrial fibrillation
Social History:
___
Family History:
From OMR: Mother died at age ___ of unclear etiology, Father at
age ___ of heart disease. Brothers with lung cancer, prostate
cancer, and heart disease. Sister with colon cancer.
Physical Exam:
Admission Physical Exam:
Vitals- ___, 114/50, 86, 20, 100%RA
General: alert and oriented
HEENT: MMM, anicteric sclera, decreased visual acuity secondary
to shingles infection.
Neck: soft, no JVD
CV: irregularly, irregular rythm
Lungs: CTA, no wheezes or ronchi
Abdomen: soft, non-tender, non-distended, BS+
GU: no CVA tenderness
Ext: dressing on the R leg and heel is clean dry and intact.
Erythema and edema more pronounce on the lateral aspect of right
leg extending from the foot to the knee. Erythematous and warm
to touch.
Neuro: CNII-XII grossly intact, motor grossly intact, speech
fluent
Skin: red, warm to touch, flakey, with evidence of purulent
drainage
Discharge Physical Exam:
Vitals: 97.8, 131/82, 18, 97% RA
General: Alert and oriented, no acute distress
HEENT: orphopharynx clear
Neck: soft, no JVD
Lungs: clear to ascultation bilaterally, no wheezes or ronchi
CV: Irregularly, Irregular
Abdomen: soft, non-tender, slightly distended, no suprapubic
tenderness or distension
Ext: dressing on the R leg and heel is clean dry and intact.
Erythema on the lateral aspect of right leg extending from the
foot to the knee. Warm to touch. Non ttp. The erythema continues
to regress from the border line drawn on ___.
Neuro: CNII-XII grossly intact and symmetric, no gross motor
deficits, speech is fluent
Pertinent Results:
Admission Labs:
___ 01:58PM LACTATE-1.1
___ 01:55PM GLUCOSE-177* UREA N-26* CREAT-0.7 SODIUM-132*
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-23 ANION GAP-17
___ 01:55PM estGFR-Using this
___ 01:55PM WBC-15.6*# RBC-3.96* HGB-11.7* HCT-33.6*
MCV-85 MCH-29.6 MCHC-34.9 RDW-13.7
___ 01:55PM NEUTS-88.4* LYMPHS-5.7* MONOS-5.8 EOS-0.1
BASOS-0.1
___ 01:55PM PLT COUNT-249
Interval Labs:
___ 05:50AM BLOOD Glucose-179* UreaN-22* Creat-0.7 Na-132*
K-4.4 Cl-97 HCO3-25 AnGap-14
___ 05:50AM BLOOD WBC-11.2* RBC-3.75* Hgb-11.0* Hct-32.2*
MCV-86 MCH-29.3 MCHC-34.2 RDW-13.7 Plt ___
___ 06:00AM BLOOD Glucose-137* UreaN-18 Creat-0.6 Na-134
K-3.7 Cl-99 HCO3-25 AnGap-14
___ 06:00AM BLOOD WBC-8.2 RBC-3.82* Hgb-11.3* Hct-32.5*
MCV-85 MCH-29.5 MCHC-34.6 RDW-13.9 Plt ___
Discharge Labs:
___ 05:50AM BLOOD Glucose-149* UreaN-21* Creat-0.7 Na-135
K-3.5 Cl-103 HCO3-23 AnGap-13
___ 05:50AM BLOOD WBC-8.6 RBC-4.05* Hgb-11.8* Hct-34.8*
MCV-86 MCH-29.1 MCHC-34.0 RDW-13.8 Plt ___
Microbiology:
___ Wound Culture:
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- <=0.25 S
PIPERACILLIN/TAZO----- 8 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Blood Cultures x2 (___): Pending
Pathology: None
Imaging/Studies:
CXR (___): IMPRESSION: Ulceration in the skin overlying the
right heel. Multi focal regions of lucency within the bones
including the calcaneus which could be due to diffuse
osteopenia. Although not particularly suspected, osteomyelitis
cannot be excluded. MRI would be more specific.
Non-ivasive arterial study of lower extremities (___):
IMPRESSION: Bilateral tibial disease, possibly some
non-compressive vessels.
The tibial disease is new compared to the prior study performed
on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Gabapentin 100 mg PO HS
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Nephrocaps 1 CAP PO DAILY
6. Omeprazole 20 mg PO BID
7. Tamsulosin 0.8 mg PO HS
8. Sodium Chloride 1 gm PO TID
9. Lorazepam 1 mg PO Q8H:PRN anxiety
10. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN pain
11. Lisinopril 40 mg PO DAILY
Hold for SBP<100
12. Ascorbic Acid ___ mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
15. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Gabapentin 100 mg PO HS
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
7. Lisinopril 40 mg PO DAILY
8. Lorazepam 1 mg PO Q8H:PRN anxiety
9. Nephrocaps 1 CAP PO DAILY
10. Sodium Chloride 1 gm PO TID
11. Tamsulosin 0.8 mg PO HS
12. Omeprazole 20 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Ciprofloxacin HCl 500 mg PO Q12H
Through ___, then stop.
16. Clindamycin 450 mg PO Q8H
Through ___, then stop.
17. Pilocarpine 1% 1 DROP RIGHT EYE Q8H
Glaucoma
18. HYDROcodone-acetaminophen *NF* 7.5-750 mg Oral BID: PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Foot ulcer
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with right heel ulcer and ascending cellulitis.
Question osteomyelitis.
COMPARISON: ___.
FINDINGS:
AP, lateral, and oblique views of the right foot. Multi focal lucencies seen
within the bones suggestive of osteopenia. Focal regions of lucency also
seen within the right calcaneus, not out of proportion to findings elsewhere
and there is no focal region of cortical disruption. There is no definite
acute fracture. Joint spaces are grossly preserved. There is soft tissue
swelling identified as well skin ulceration within the subcutaneous tissues
overlying the calcaneus. There is no radiopaque foreign body or subcutaneous
gas. Small vessel atherosclerotic calcifications are noted.
IMPRESSION:
Ulceration in the skin overlying the right heel. Multi focal regions of
lucency within the bones including the calcaneus which could be due to diffuse
osteopenia. Although not particularly suspected, osteomyelitis cannot be
excluded. MRI would be more specific.
Radiology Report
HISTORY: Right heel ulcer, diabetes.
FINDINGS: The ABI on the right is 1.0 and the ABI on the left is 1.21.
Doppler tracings are triphasic through the popliteal levels bilaterally and
monophasic at the tibial levels bilaterally. Volume recordings demonstrate
some waveform widening at the ankle and metatarsal levels bilaterally.
IMPRESSION: Bilateral tibial disease, possibly some non-compressive vessels.
The tibial disease is new compared to the prior study performed on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R LEG SWELLING
Diagnosed with CELLULITIS OF FOOT
temperature: 97.0
heartrate: 85.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 61.0
level of pain: 10
level of acuity: 3.0 | ___ with multiple medical problems including COPD, DM, PAD, NHL,
and atrial fibrillation (not anticoagulated) presenting with
right leg swelling and redness concerning for cellulitis vs
osteomyeltis.
Active Diagnoses:
#. Right foot/heel wound
Pt with DM and PVD with chronic wound on right foot. Presenting
with worsening swelling, redness and pain. Imaging with regions
of luceny which were felt to be osteopenia vs osteomyelitis. He
was seen by podiatry in the ED, who were unable to probe to
bone, but felt that he required IV antibiotics. He had a
non-invasive study on ___ to access his arterial flow in the
LEs. The arterial study of the lower extremities showed
bilateral tibial disease. Switched Cipro to PO on ___. On
___ had Right heel debridement at bedside. His foot bled
during the debridement yesterday meaning that Vascular will
follow up with him as an outpatient. Leukocytosis improving.
Wound culture grew out psuedomonas (cipro sensitive) and Coag+
staph on ___. He will continue with Cipro and Clindamycin as
an outpatient until ___.
Of note, after discharge, culture sensitivities revealed
clinda-resistant MRSA. Rehab was contacted, and the patient was
switched to cipro/bactrim. His renal function should be
monitored while he is on bactrim.
# BPH: Patient uses diapers. He had 990cc in his bladder on the
evening of ___. He received a foley catheter on ___ and his
suprapubic pain resolved. Continued tamsulosin. Foley will
likely be discontinued in rehab on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Levofloxacin / lisinopril
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with Child's A alcohol/HCV cirrhosis c/b
varices, ETOH abuse, type 2 diabetes, chronic pancreatitis
presenting with ETOH intoxication and right hip pain.
Transferred from home for slurred speech and altered mental
status, and reporting traumatic right hip pain that per patient
is a hip fracture that does not require surgery, and otherwise
here has been belligerent towards staff. Patient refusing to
participate in exam other than attending to kick providers with
both legs demonstrating full range of motion and good strength
in the right lower extremity.
On arrival to the MICU, the patient states that she is still
feeling tremulous and anxious. She reports that she has been
having pain in her right hip for the past month. She has daily
nausea and vomiting, which hasn't changed since admission. She
also denies diarrhea, although she is not sure when she finished
her course of treatment for C. diff. She thinks her visiting
nurse ___ have identified a fever ___ F at home but no chills
or sweats.
Past Medical History:
1. Diabetes complicated by peripheral neuropathy, h/o DKA
2. Depression
3. Recurrent Alcohol Abuse with multiple admissions for detox,
no h/o DT or w/d seizures
4. Alcoholic hepatitis
5. Chronic pancreatitis
6. Cirrhosis/varices by MRI
7. Prior suicidal ideation ___
8. GERD
9. HTN
Social History:
___
Family History:
Mother - died of ___
Brother - died of ___
Brother - DM
Physical ___:
On Admission Physical Exam
==========================
VITALS: afebrile, BP 150/80s, HR ___, RR 20, satting 98% RA
GENERAL: Alert, oriented, no acute distress but tremulous
without asterixis
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no tenderness over the right hip, no effusion
SKIN: no rash noted
NEURO: moving all extremities spontaneously
On Discharge Physical Exam
==========================
VITALS: 98.3 BP 118/68 HR 105 RR 18 O2: 93% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no tenderness over the right hip, no effusion
SKIN: no rash noted
NEURO: moving all extremities spontaneously, minimal UE tremor,
no tongue fasciculations
Pertinent Results:
In the ED ___
===============
___ 05:35PM BLOOD ___
___ Plt ___
___ 05:35PM BLOOD ___
___
___ 05:35PM BLOOD ___
___ 05:35PM BLOOD ___
___ 05:35PM BLOOD ___
___ 05:35PM BLOOD ___
___ 05:35PM BLOOD ___
___ 05:35PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD ___
___ Base ___
___ 08:06PM BLOOD ___
On Arrival to MICU ___
=======================
___ 07:14AM BLOOD ___
___ Plt ___
___ 07:14AM BLOOD ___ ___
___ 07:14AM BLOOD ___
___
___ 07:14AM BLOOD ___ LD(LDH)-225 ___
___
At Discharge from MICU ___
===========================
___ 03:50PM BLOOD ___
___
___ 04:15PM BLOOD ___
Imaging
=======
___ CT A/P:
1. The pancreas has normal attenuation enhancement throughout
without evidence of pancreatic ductal dilatation. No evidence of
pancreatic necrosis or peripancreatic fluid collections or
stranding. Please note that CT findings of pancreatitis ___ lag
clinical findings by up to 48 hours.
2. There is an unchanged 0.5 cm hypodensity in the pancreatic
tail, which is nonspecific, but likely represents a side branch
IPMN. This is been stable since at least ___,
suggestive of benignity.
3. Massive dilatation of the urinary bladder
___ RUQ US:
Limited exam. Slightly nodular contour of the liver should be
correlated for underlying cirrhosis. No evidence of gallstones
or choledocholithiasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. BusPIRone 15 mg PO TID
3. Creon 12 1 CAP PO TID W/MEALS
4. DULoxetine 60 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Simethicone ___ mg PO QID:PRN gas pain
9. amLODIPine 5 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. TraZODone 50 mg PO QHS:PRN insomnia
14. 70/30 7 Units Breakfast
70/30 7 Units Lunch
70/30 7 Units Dinner
degludec 65 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 8 hours Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [___] 5 mg 1 tablet(s) by mouth every day
Disp #*30 Tablet Refills:*0
3. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*2 Tablet Refills:*0
4. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin ___ 1,000 mcg 1 tablet(s) by mouth
every day Disp #*30 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine ___ [MTX] 4 %-1 % 1 patch every day Disp
#*30 Patch Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides ___ (sennosides)] 8.6 mg 1 tab by mouth
every day Disp #*30 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth every
day Disp #*30 Tablet Refills:*0
10. 70/30 7 Units Breakfast
70/30 7 Units Lunch
70/30 7 Units Dinner
degludec 65 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100
unit/mL (___) AS DIR 7 SC 7 Units before BKFT; 7 Units before
LNCH; 7 Units before DINR; Disp #*90 Syringe Refills:*0
RX *blood sugar diagnostic [Accutrend Glucose] 1 strip TID
Three times a day with meals Disp #*100 Strip Refills:*0
RX ___ meter [Advanced Glucose Meter] 1 meter three
times a day Disp #*1 Each Refills:*0
RX *lancets [___] 23 gauge one lancet three
times a day three times a day Disp #*100 Each Refills:*0
RX *insulin degludec [Tresiba FlexTouch ___ 100 unit/mL (3
mL) AS DIR 65 SC 65 Units before BKFT; Disp #*30 Syringe
Refills:*0
11. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
12. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
13. BusPIRone 15 mg PO TID
RX *buspirone 15 mg 1 tablet(s) by mouth every 8 hours Disp #*90
Tablet Refills:*0
14. Creon 12 1 CAP PO TID W/MEALS
RX ___ [Creon] 12,000 ___
___ unit 1 capsule(s) by mouth every 8 hours with meals
Disp #*90 Capsule Refills:*0
15. DULoxetine 60 mg PO DAILY
RX *duloxetine [Cymbalta] 60 mg 1 capsule(s) by mouth every day
Disp #*30 Capsule Refills:*0
16. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
17. Losartan Potassium 50 mg PO DAILY
RX *losartan [Cozaar] 50 mg 1 tablet(s) by mouth every day Disp
#*30 Tablet Refills:*0
18. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin [Fortamet] 1,000 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*0
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
21. Simethicone ___ mg PO QID:PRN gas pain
RX *simethicone ___ Ultra Strength] 180 mg 1 tab by mouth
___ 6 hours Disp #*120 Capsule Refills:*0
22. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
23.Equipment
1 Rolling Walker
No refills
Use daily
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Withdrawal
Urinary Tract Infection
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: Right hip pain status post fall.
COMPARISON: CTU dated ___.
FINDINGS:
AP view of the pelvis and AP and lateral views of the right hip were provided.
The bony pelvic ring is intact. SI joints are symmetric and normal. Imaged
lower lumbar spine is unremarkable. Both hips align anatomically without
significant osteoarthritis. The femoral necks appear intact bilaterally.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CHEST (P AP a AND LAT)
INDICATION: ___ with epigastric pain// ? effusion
COMPARISON: Prior exam is dated ___
FINDINGS:
AP upright and lateral views of the chest provided. No free air seen below
the right hemidiaphragm. Lungs are clear. There is no focal consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette is stable. Imaged
osseous structures are intact. Chronic right seventh rib deformity again
noted.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with pancreatitis, recurrent// ? choledocolithiasis/CBD
dilation
TECHNIQUE: Right upper quadrant ultrasound, patient refused portions of the
exam due to discomfort during scanning.
COMPARISON: CT of the abdomen pelvis from ___
FINDINGS:
Subtle nodularity along the hepatic contour raises potential concern for
cirrhosis. Please note the majority of the right lobe was poorly visualized
due to under penetration and poor access. No perihepatic ascites. No
intrahepatic biliary ductal dilation. Main portal vein is patent with
hepatopetal flow. The gallbladder appears normal without stones or evidence
of acute cholecystitis. The common bile duct measures up to 5 mm in diameter.
The spleen is within normal limits at 12 cm in length. Pancreas is poorly
visualized.
IMPRESSION:
Limited exam. Slightly nodular contour of the liver should be correlated for
underlying cirrhosis. No evidence of gallstones or choledocholithiasis.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with rising lactate and abdominal pain. Evaluate for
necrotizing pancreatitis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis prior to and 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 2.9 s, 31.5 cm; CTDIvol = 14.7 mGy (Body) DLP = 463.8
mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
3) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol = 14.9 mGy (Body) DLP = 803.9
mGy-cm.
Total DLP (Body) = 1,280 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates decreased density throughout, consistent
with hepatic steatosis. There are a few subcentimeter hypodensities scattered
throughout the liver, too small to characterize. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation and enhancement throughout,
without evidence of pancreatic ductal dilatation. No evidence of
peripancreatic fluid collections. Unchanged 0.5 cm hypodensity in the
pancreatic tail (___), which is nonspecific, but likely represents a side
branch IPMN. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. Small medial small accessory spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are bilateral subcentimeter hypodensities, too small to characterize.
No hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. Otherwise, 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 massively distended. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There are multiple mesenteric nodes, measuring up to 1.0 cm in
short axis (___). There is no retroperitoneal 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: Tiny fat containing umbilical hernia. Otherwise, the abdominal
and pelvic wall is within normal limits.
IMPRESSION:
1. The pancreas has normal attenuation enhancement throughout without evidence
of pancreatic ductal dilatation. No evidence of pancreatic necrosis or
peripancreatic fluid collections or stranding. Please note that CT findings
of pancreatitis may lag clinical findings by up to 48 hours.
2. There is an unchanged 0.5 cm hypodensity in the pancreatic tail, which is
nonspecific, but likely represents a side branch IPMN. This is been stable
since at least ___, suggestive of benignity.
3. Massive dilatation of the urinary bladder.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ETOH, R Hip pain
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 97.8
heartrate: 98.0
resprate: 16.0
o2sat: 95.0
sbp: 169.0
dbp: 88.0
level of pain: 3
level of acuity: 3.0 | SUMMARY: Ms. ___ is a ___ lady with a PMH of
alcoholic and HCV cirrhosis (Childs A) complicated by varices,
alcohol abuse,
chronic pancreatitis, and diabetes, who presented to the ___
ED
initially with slurred speech, AMS, and right hip pain, found to
be intoxicated and now s/p phenobarbital loading for high risk
of
withdrawal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Major Surgical or Invasive Procedure:
___ Cardiac catheterization, DES x2 RCA
attach
Pertinent Results:
ADMISSION LABS
==============
___ 03:40PM BLOOD WBC-24.7* RBC-4.83 Hgb-11.4* Hct-37.4*
MCV-77* MCH-23.6* MCHC-30.5* RDW-15.5 RDWSD-41.6 Plt ___
___ 03:40PM BLOOD Neuts-88.0* Lymphs-4.3* Monos-6.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-21.75* AbsLymp-1.05*
AbsMono-1.54* AbsEos-0.00* AbsBaso-0.04
___ 03:40PM BLOOD Glucose-272* UreaN-85* Creat-2.5* Na-136
K-6.9* Cl-103 HCO3-17* AnGap-16
___ 05:45PM BLOOD Albumin-3.7 Calcium-9.0 Phos-5.7* Mg-2.2
___ 05:45PM BLOOD ALT-50* AST-186* AlkPhos-83 TotBili-0.3
___ 05:45PM BLOOD ___ PTT-30.7 ___
PERTINENT LABS
==============
___ 05:45PM BLOOD cTropnT-7.01*
___ 06:46PM BLOOD cTropnT-6.31* ___
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-9.5 RBC-4.83 Hgb-11.5* Hct-36.5*
MCV-76* MCH-23.8* MCHC-31.5* RDW-14.5 RDWSD-38.2 Plt ___
___ 07:00AM BLOOD ___ PTT-29.3 ___
___ 07:00AM BLOOD Glucose-241* UreaN-42* Creat-1.5* Na-132*
K-5.1 Cl-98 HCO3-22 AnGap-12
IMAGING/OTHER STUDIES
=====================
___ EKG
NSR, ST-Elevations in II, III, aVF
___ CARDIAC CATH
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. The Diagonal, arising from the
proximal segment, is a medium caliber vessel. The Septal
Perforator, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. The ___ Obtuse Marginal, arising from the
proximal segment, is a medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 100%
stenosis in the proximal segment. There is a moderate thrombus
in the proximal and mid segments.
There is a 70% stenosis in the proximal and mid segments.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
Collaterals from the distal segment of the SP connect to the
proximal segment.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Single vessel coronary artery disease
Maximize medical therapy
DAPT for 12 mo with ASA/Ticagrelor. Routine post-STEMI care
2 DES to RCA
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. clotrimazole 1 % topical BID
2. Docusate Sodium 200 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
4. HydrALAZINE 50 mg PO Q8H
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Metoclopramide 10 mg PO QIDACHS
7. Omeprazole 20 mg PO BID
8. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line
9. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Severe
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
11. Senna 8.6 mg PO BID
12. amLODIPine 10 mg PO DAILY
13. Amphotericin B Ophth Soln 0.1% 1 DROP OD BID
14. Atorvastatin 40 mg PO QPM
15. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H
16. Moxifloxacin 0.5% Ophth (*NF*) 1 DROP OD Q6H eye infection
17. Polyethylene Glycol 17 g PO DAILY
18. Sarna Lotion 1 Appl TP QID:PRN itching
19. Sodium Bicarbonate 1300 mg PO BID
20. Sodium Chloride 1 gm PO BID
21. Multivitamins W/minerals 1 TAB PO DAILY
22. patiromer calcium sorbitex ___ gram oral DAILY
23. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
24. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
25. Glargine 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
4. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Glargine 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Metoclopramide 5 mg PO TIDAC
RX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day
before meals Disp #*90 Tablet Refills:*0
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H
9. clotrimazole 1 % topical BID
10. Docusate Sodium 200 mg PO DAILY
11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
12. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Omeprazole 20 mg PO BID
15. Ondansetron 8 mg PO BID:PRN Nausea/Vomiting - First Line
16. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 3 tablet(s) by mouth four times a day Disp
#*12 Tablet Refills:*0
17. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day
Disp #*2 Tablet Refills:*0
18. patiromer calcium sorbitex ___ gram oral DAILY
19. Polyethylene Glycol 17 g PO DAILY
20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID
21. Sarna Lotion 1 Appl TP QID:PRN itching
22. Senna 8.6 mg PO BID
23. Sodium Bicarbonate 1300 mg PO BID
24. Sodium Chloride 1 gm PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
RCA STEMI s/p PCI
CAP
Secondary diagnoses:
Hyperkalemia
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with altered mental status // eval PNA
COMPARISON: Prior chest CT from ___ and chest radiograph from ___
FINDINGS:
AP portable semi upright view of the chest. A fiducial projecting over the
left perihilar region is unchanged in position. There is a subtle
ground-glass opacity projecting over the right lower lung which could
represent a developing pneumonia in the correct clinical setting. Elsewhere,
lungs are clear. Small surgical clips project over the right mediastinal
border. Cardiomediastinal silhouette is stable. Bony structures are intact.
IMPRESSION:
Subtle opacity at the right lung base could represent a developing pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by UNKNOWN
Chief complaint: Diarrhea, Weakness
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.3
heartrate: 95.0
resprate: 18.0
o2sat: 94.0
sbp: 117.0
dbp: 67.0
level of pain: 10
level of acuity: 3.0 | TRANSITIONAL ISSUES:
=====================
[] Medications STARTED: Lisinopril 5, atorvastatin increased
from 40 to 80 daily, ASA 81, ticagrelor 90 BID, Coreg 6.25 BID
[] Medications STOPPED: amlodipine 10 daily, hydralazine 50 q8h,
isosorbide mononitrate 30 daily
[] Cardiology:
Discharge Cr: 1.5
Discharge Weight: 131.83
- We started him on an ACEi while inpatient. His kidney function
was stable prior to discharge.
[] Follow up blood pressures as an outpatient and consider
restarting amlodipine or hydralazine as indicated (see meds that
were held above)
[] He was being given 7u Lantus in the evening. We discharged
him on this, but he had been prescribed 10u prior to admission
and reported taking ___ each evening. Can titrate his Lantus at
follow-up.
SUMMARY
=====================
___ yr old male with a history of CAD with NSTEMI in ___, CKD,
gastroparesis, chronic pancreatitis, NSCLC s/p XRT, diabetes,
hypertension, and blindness who presented with weakness and
confusion found to have inferior STEMI s/p DES x2 to RCA. His
course was complicated by pneumonia, hyperkalemia, and ___ on
CKD.
#CORONARIES: ___ RCA 100% in proximal segment and 70%
stenosis in the proximal and mid segments.
#PUMP: Mild symmetric LV hypertrophy with small cavity and
normal regional and global LV systolic function. EF 55-60%.
Dilated RV cavity with SEVERE global free wall hypokinesis.
Abnormal interventricular septal wall mition c/w RV pressure and
volume overload. Mild MR, mod/severe TR.
#RHYTHM: NSR
ACTIVE ISSUES:
===============
# Inferior STEMI s/p DES x2 to RCA
Patient presented with weakness and confusion, without chest
pain, and was found to have inferior STEMI. Taken to cath lab,
now s/p DES x2 to RCA. He required a brief stay in the CCU for
post-catheterization hypotension, which improved with IVF. TTE
showed preserved EF but severely hypokinetic RV. He was started
on ASA, ticagrelor, atorvastatin and metoprolol following his
catheterization, but was switched from metoprolol to carvedilol
prior to discharge and tolerated it well. He was started on
Lisinopril 5 on day of discharge.
# Community Acquired Pneumonia
Patient presented with weakness and confusion and wife noted
several weeks of coughing. He denied fevers and remained
afebrile while inpatient, but had a WBC count of 26 with
neutrophilic predominance and left shift and concern for R
basilar opacity on CXR. He was treated with ceftriaxone and
azithromycin, which he completed prior to discharge and his WBC
trended down.
# ___ with hyperkalemia
Recent admissions for ___, with baseline Cre around 1.2-1.4.
Admitted with Cre of 2.5. ___ thought to be pre-renal in the
setting of CAP and poor PO intake for several days prior to
admission. K 6.9 on arrival and patient was treated with calcium
gluconate and insulin with a bolus of D50. He has a history of
hyperkalemia, on daily patiromer and low-K diet, and the
hyperkalemia was thought to be related to ___ in the setting of
chronic hyperkalemia. His ___ patiromer was not continued while
in the hospital due to its being nonformulary. His K normalized
while in the hospital.
# Delirium: patient with mild confusion on admission to the
floor, but rapidly improved to baseline. Felt to be
multifactorial in the setting of multiple factors placing him at
risk for delirium including infectious process, recent MI and
chronic opiates. His mental status returned to baseline prior to
discharge, but he remains persistently weak which appears
consistent with his baseline.
# Epigastric Pain
Patient complaining of epigastric abdominal pain. Per patient is
similar to his baseline pain from his chronic pancreatitis and
gastroparesis. Lipase not elevated to indicate acute
pancreatitis. Patient with mild elevation in ALT/AST after going
to the cath lab for STEMI, thought to be related to brief
hypotension. Downtrended to normal prior to discharge. As
patient with history of HCV, viral load was sent but result did
not return prior to discharge.Pain is similar to baseline. He
was continued on his ___ omeprazole and pain regimen while
inpatient. His ___ Zofran was held due to azithromycin therapy
and patient did not have need for it.
CHRONIC ISSUES:
================
# Type II diabetes
History of type 2 DM with last A1c- 8.3. Patient was discharged
in ___ with plan for glargine 10u qhs, however his wife reports
giving him between ___ units qhs based on his blood sugar. He
was continued with glargine ___ qhs and ISS TID while
inpatient.
# History of Iron deficiency Anemia
Patient was continued on his ___ ferrous sulfate qod. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ THORACENTESIS
History of Present Illness:
___ F with a history of atrial fib on ___ with recent
fall resulting in ___ in ___ complicated by rib fractures
and right sided pleural effusion that required drainage presents
with recurrent effusion and SOB.
In terms of her pleural effusion, her daughter reports that it
was first discovered by the patients cardiologist after Ms.
___ was complaining of shortness of breath. A CXR was done
for further evaluation which revealed a pleural effusion. The
pleural effusion, however, is noted on prior CXRs from ___ (unavaible in our system, only per reports in radiology
reports). She was going to be evaluated by IP but then she
suffered a ___ and her pleural effusion was managed as an
inpatient (see below).
She was last hospitalizated from ___ where she had a ___
and also underwent drainage of the known pleural effusion. She
had an uncomplicated removal of 2.5 liters of exudative effusion
(Tprot pleural fluid/Tprot serum >0.5). CT chest after drainage
showed
trapped lung with residual pneumothorax but no effusion. She was
going to follow-up with IP as an outpatient for further
management of her pleural effusion. The pleural effusion was
thought to be secondary to trauma from rib fractures related to
her fall.
She presents from ___ today for increasing SOB. Her
SOB was intermittent after her time post-discharge. She noted
that it was worse when it was going to rain. She went her PCP on
___ for a follow-up visit where a CXR showed reaccumulation
of right effusion. She became increasingly SOB with exertion the
day prior to admission and SOB worse with lying flat so she went
for evaluation at ___. She also described wheezing and
cough. She was then transferred to ___ for further management.
In the ED, initial vitals were:
97.8 85 170/111 18 98%
Labs in the ED notable for WBC 4.9, Hg 12.1, Plts 106. Chem 7
with sodium 141, potassium 4.1, Cl 104, BUN 24, BUN 16, Cr 1.0,
INR 1.3.
On the floor, she reports feeling comfortable in bed in terms of
her respiratory status. She does have a headache.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- traumatic small right-sided SDH and left parietal SAH
- atrial fibrillation (off coumadin since ___
- silent L cerebellar CVA (seen on imaging, patient denies this)
- hypertension
- hyperlipidemia
- osteoarthritis
- L knee replacement
- R hip replacement
Social History:
___
Family History:
Mother - CVA in her ___
Father - MI in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 ___ 94%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds over the right lung, CTA on the
left
CV: Irregularly irregular, 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
Skin: WWP, no edema
Neuro: CN II-XII intact
DISCHARGE PHYSICAL EXAM:
Vitals: T: 97.9 BP:114/87 P:86 RR:18 O2stat:98%RA
General: Alert, oriented, anxious, normal speech.
HEENT: No JVD, no LAD
Lungs: Right lung with crackles and diminished aeration at base,
but much improved from ___. Left lung with crackles at the
base.
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or lesions
Neuro: Alert & oriented, no focal neuro deficit, no facial
assymetry,
MSK: On hands bilaterally, there is ulnar deviation of the
digits. No ulnar deviation at the wrists. ___ nodes;
rare Heberdon's nodes. Hallux abducto valgus deformity of the
feet bilaterally.
Skin: No rash
Pertinent Results:
ADMISSION LABS:
___ 06:40PM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
___ 06:40PM estGFR-Using this
___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8*
BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34
AbsEos-0.57* AbsBaso-0.06
___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8*
BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34
AbsEos-0.57* AbsBaso-0.06
___ 06:40PM PLT COUNT-279
___ 06:40PM ___ PTT-32.3 ___
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE UHOLD-HOLD
___ 04:35PM URINE GR HOLD-HOLD
___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
PERTINENT RESULTS: PLEURAL FLUID STUDIES
___ 12:40PM PLEURAL WBC-460* RBC-1090* Polys-0 Lymphs-11*
Monos-2* Eos-86* NRBC-2* Macro-1*
___ 12:40PM PLEURAL Hct,Fl-UNABLE TO
___ 12:40PM PLEURAL TotProt-3.1 Glucose-122 Creat-0.9
LD(LDH)-132 Amylase-27 Albumin-2.0 Cholest-51
___ 12:40PM PLEURAL Misc-PRO BNP =
DISCHARGE LABS:
___ 07:07AM BLOOD WBC-5.8 RBC-3.53* Hgb-11.9 Hct-37.1
MCV-105* MCH-33.7* MCHC-32.1 RDW-14.0 RDWSD-53.3* Plt ___
___ 07:07AM BLOOD Plt ___
___ 07:07AM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-138
K-3.9 Cl-102 HCO3-24 AnGap-16
IMAGING:
___ CXR FROM ___ HOSP: large right sided pleural
effusion
___ CXR In comparison with the study of ___, there is
little change in the pleural
effusion extending upward to the midportion of the right lung
with associated
volume loss in the right lower and possibly right middle lobe.
The left lung
is essentially clear and there is no evidence of vascular
congestion.
___ CXR Right pleural effusion is resolved. No pneumothorax
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. Apixaban 2.5 mg PO BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Carvedilol 25 mg PO BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. LaMOTrigine 50 mg PO QHS
RX *lamotrigine 100 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
RX *lamotrigine 100 mg ___ tablet(s) by mouth twice/day Disp
#*60 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Pleural effusion
2. Possible partial temporal lobe seizures.
SECONDARY DIAGNOSES:
1. Hypertension
2. Atrial fibrillation
3. Arthritis
4. H/o ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with known effusion // eval for any interval
change in pleural effusion eval for any interval change in pleural
effusion
IMPRESSION:
In comparison with the study of ___, there is little change in the pleural
effusion extending upward to the midportion of the right lung with associated
volume loss in the right lower and possibly right middle lobe. The left lung
is essentially clear and there is no evidence of vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pleural effusion, now with increased SOB,
sat's stable at 98 on 2L, please eval for growing effusion // please eval for
growing effusion please eval for growing effusion
COMPARISON: Prior chest radiographs ___.
IMPRESSION:
Moderate to large right pleural effusion is unchanged. No pneumothorax.
Right lung base is obscured and substantially atelectatic. Apparent increase
in cardiac silhouette size is due in part to adjacent pleural effusion. Left
lung clear. Heart size normal.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with ___ year old woman on heparin drip, hx of
sdh/sah, nwo with word finding difficulties, concern for tia vs stroke. //
any head bleed or evidence of acute stroke?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 5.6 s, 14.6 cm; CTDIvol = 53.8 mGy (Head) DLP =
785.0 mGy-cm.
Total DLP (Head) = 785 mGy-cm.
COMPARISON: ___ noncontrast CT head.
FINDINGS:
There is no evidence of major vascular territory infarction, new intracranial
hemorrhage, edema, or mass. The ventricles and sulci are mildly prominent,
suggestive of age-related involutional changes. Scattered periventricular
white-matter hypodensities are present, consistent with chronic small vessel
ischemic disease. There is evidence of mild encephalomalacia in the left
posterior occipital, unchanged from prior imaging.
No osseous abnormalities are seen. 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 new hemorrhage.
Radiology Report
INDICATION: ___ year old woman with right pleural effusion s/p thoracentesis.
// assess for PTX or other complication of thoracentesis
EXAMINATION: CHEST (PORTABLE AP)
TECHNIQUE: Portable chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Previously seen large right pleural effusion is now resolved. There is no
consolidation or pneumothorax. Cardiomediastinal silhouette is normal size.
Tortuous aortic contour is stable.
IMPRESSION:
Right pleural effusion is resolved. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with PLEURAL EFFUSION NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.8
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 170.0
dbp: 111.0
level of pain: 0
level of acuity: 2.0 | In brief this is a ___ yr old female who has a hx of Afib on
Apixaban, hypertension, recent admission for fall w/ traumatic
SDH & SAH, recent admission for a ___ complicated by rib
fractures and right sided hemorrhagic pleural effusion, now
presenting with SOB and found to have recurrent right pleural
effusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine
Attending: ___
___ Complaint:
Nausea/vomiting and abdominal distension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per OMR: ___ with colon adenocarcinoma presents ___ s/p open
left
colectomy w/ primary handsewn anastomosis and extensive LOA
(prior abdominal surgeries) with intractable nausea and
nonbloody, nonbilious emesis x2 days since arriving home
following his most recent ED visit.
Patient initially had an uneventful post-op course and was
discharged home on POD2. He was doing well until POD3 when he
began experiencing worsening abdominal pain, nausea, dry heaves,
and dysphagia with a foreign body sensation in his throat.
Evaluation in our ED on POD 6 with barium swallow demonstrated
no
abnormalities. He was discharged home following a PO trial.
Per Mr. ___ report, following his arrival home from the ED
(now approximately 48 hours ago) he began experiencing
intractable nausea and nonbloody/nonbilious vomiting and was
unable to keep any liquids or solids down. He senses that
whatever "obstructed feeling" he had in his throat prior is now
totally gone. He was seen earlier today at ___ for this
complaint and underwent CT AP as part of his workup prior to
transfer. His last episode of vomiting was approximately 12
hours
ago at the time of interview. Mr. ___ denies constipation,
obstipation, or distension. He does endorse abdominal pain which
is worse during wretching and which he is unable to localize. He
is passing ___ small liquid/semiformed BM per day and is passing
gas. He denies fevers, chills, nightsweats, sick contacts,
recent
travel, trying new foods.
Past Medical History:
PMH: HTN, HLD, colon adenocarcinoma
PSH:
-Diagnostic laparoscopy converted to open laparotomy with
extensive LOA and left colectomy w/ primary handsewn
anastomosis
___, ___
-Ex-lap with right nephrectomy and colon resection
(trauma; fall from approx 30 feet) ----- [previously left
nephrectomy and splenectomy were documented however this is
contradicted by imaging]
-Hernia repair (___)
-Cholecystectomy (___)
Social History:
___
Family History:
No family history of colorectal malignancy
Physical Exam:
T 97.8, BP 101/64, HR 55, RR 16, 98% RA
Gen: AxO3
CV: RRR
Pulm: No respiratory distress.
Abd: Soft, less distended, minimally tender at midline
incision only; less tender in LLQ; midline incision c/d/i with
steri-strips over. No drainage.
Ext: Warm, no edema.
Pertinent Results:
___ 09:50AM BLOOD WBC-9.8 RBC-3.44* Hgb-10.1* Hct-30.3*
MCV-88 MCH-29.4 MCHC-33.3 RDW-12.7 RDWSD-41.1 Plt ___
___ 03:26AM BLOOD WBC-7.3 RBC-3.46* Hgb-10.3* Hct-31.1*
MCV-90 MCH-29.8 MCHC-33.1 RDW-12.9 RDWSD-42.2 Plt ___
___ 09:50AM BLOOD Plt ___
___ 03:26AM BLOOD Plt ___
___ 03:26AM BLOOD ___ PTT-25.1 ___
___ 09:50AM BLOOD Glucose-109* UreaN-16 Creat-1.0 Na-140
K-4.2 Cl-101 HCO3-24 AnGap-15
___ 05:16PM BLOOD Glucose-99 UreaN-20 Creat-1.1 Na-139
K-4.1 Cl-100 HCO3-27 AnGap-12
___ 03:26AM BLOOD Glucose-190* UreaN-18 Creat-1.1 Na-136
K-3.8 Cl-96 HCO3-25 AnGap-15
___ 03:26AM BLOOD ALT-42* AST-34 AlkPhos-86 TotBili-0.5
___ 09:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8
___ 05:16PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Acetaminophen 1000 mg PO Q8H
4. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
5. amLODIPine 10 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Ileus/GI motility dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ s/p open segmental left colectomy for adenoCa ___ p/w n/v,
unclear etiology// Evaluate for contrast load.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There is enteric contrast seen extending through the colon to the rectum. The
transverse colon is prominent. There is evidence of diverticulosis of the
residual descending and sigmoid colon. There is residual enteric contrast
seen in the distal small bowel. There are some prominent small bowel loops
without pathological dilation.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are surgical clips seen in the right upper quadrant. There are multiple
rounded radiopacities within the pelvis that likely represent phleboliths.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
The visualized lung bases appear clear.
IMPRESSION:
1. The enteric contrast is seen progressing through the colon to the rectum.
There is a significant amount of residual enteric contrast. No evidence of
obstruction.
2. Diverticulosis of the remnant left colon and sigmoid.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 98.6
heartrate: 60.0
resprate: 16.0
o2sat: 97.0
sbp: 135.0
dbp: 74.0
level of pain: 7
level of acuity: 3.0 | Mr ___ presented to ___ holding at ___ on ___
for ongoing, nausea/ vomiting and abdominal pain. He was
conservatively managed with suppositories for comfort until
normalized and bowel function resumed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea, vomiting, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old ___ speaking man with a
history of HTN, HLD, insulin resistance, lumbar stenosis,
peripheral edema, who was diagnosed with posterior circulation
strokes 2 months ago in ___, presenting with worsening
dizziness, nausea, and vomiting with subacute decline in the
last
month.
The patient was hospitalized 2 months ago in ___ for 20 days
for visual loss (he described that the L side of the world
looked black, and the R looked blurry), nausea, vomiting, and
dizziness. He was found to have posterior circulation strokes
with bilateral occipital and cerebellar involvement per report
of his son at the bedside. Etiology was felt to be due to a R
vertebral artery plaque and he was started on ASA 81,
simvastatin 20, metformin, and nifedipine. The son also notes
that he was told there is extensive plaque in all of his vessels
including one of his carotid arteries as well.
One month ago the patient flew to ___ to visit his son and
daughter in law who recently had a child in order to help out.
However, since then he has been getting gradually progressively
worse, although his course has been fluctuating throughout. He
continues to feel vertiginous almost continuously, although the
feeling will occasionally subside for several minutes. He cannot
identify anything that triggers the dizziness such as positional
changes, and notes that it can be exacerbated for ___ minutes
at a time randomly, when he is lying quietly or when he is
walking. He is nauseous and vomits multiple times per day. Since
his stroke his vision has been slowly gradually impoving and he
has regained some vision on the L side which he had lost, but
notes that his entire field remains blurry. Denies double
vision. No dysarthria or dysphasia. No aphasia noted by family
members. He has not been walking well and is very off balance
all of the time. He does endorse a ___ headache which is mild.
The patient saw his PCP today who referred him to a vascular
surgeon, however, the vascular surgeon called and said he could
not handle these symptoms so the patient was sent to the ED.
On neurologic review of systems, the patient denies difficulty
with producing or comprehending speech. Denies diplopia,
dysarthria, or dysphagia. Denies muscle weakness. Denies loss of
sensation. Endorses generalized weakness
On general review of systems, the patient denies fevers, rigors.
Denies chest pain, endorses occasional SOB. Denies nausea,
vomiting, diarrhea, constipation, or abdominal pain.
Past Medical History:
- HTN
- HLD
- posterior circulation stroke 2 months ago
- insulin resistance
- peripheral edema
- lumbar stenosis: at baseline can only walk for 20 minutes
before he needs to rest
Social History:
___
Family History:
Mother - DM
Physical ___:
ADMISSION PHYSICAL EXAM:
VS 98.6 95 141/70 18 93%
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Skin: No rashes or lesions
Swallow: the patient passed by bedside swallow exam
Neurologic Examination:
- Mental Status - Exam preformed with assistance of daughter in
law translating
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling days
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (although this is limited by poor visual acuity)
and no paraphasias. Describes that there is a child and a woman
in the stroke picture but is unable to see what they are doing,
able to name "hand" but not other stroke card objects since he
says he cannot see. Normal prosody. No dysarthria. Verbal
registration and recall ___. No evidence of hemineglect.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupil. Visual fields were grossly full to
finger wiggling however patient endorses very poor visual
acuity,
worse on the L.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus, although the patient endorses double
vision when gazing L.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
To extinction to DSS
- DTRs -
Bic Tri ___ Quad Gastroc
L 1 1 1 0 0
R 1 1 1 1 0
Plantar response flexor bilaterally.
- Cerebellar -
Mild bilateral dysmetria L>R
- Gait -
Patient able to stand without assistance although looks wobbly
and stands with a cautions, wide based gait and takes several
hesitant steps. Not able to close eyes and ___ in place since
he almost falls over.
======================================================
DISCHARGE PHYSICAL EXAM:
VS 98.0 151/71 60 18 97% RA
General: NAD, lying in bed with an icepack on forehead.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status
Awake, alert, oriented x 3. Attention to examiner easily.
Concentration maintained when recalling days backwards. able to
name common and uncommon things. Recalls a coherent history
consistently. Normal prosody. No dysarthria. No evidence of
hemineglect.
- Cranial Nerves -
I. not tested
II. Pupil equal, round and reactive to light. Visual fields were
grossly full to finger number flashing, however patient endorses
very poor visual acuity,
worse on the L but improving from two months ago.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus, denies diplopia.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
intact to light touch, temperature, and pain
- DTRs -
Bic Tri ___ Quad Gastroc
L 1 1 1 0 0
R 1 1 1 1 0
Plantar response flexor bilaterally.
- Cerebellar -
mild bilateral dysmetria
- Gait -
not tested
Pertinent Results:
ADMISSION LABS:
___ 05:33PM NEUTS-71.2* ___ MONOS-6.5 EOS-1.0
BASOS-0.6
___ 05:33PM WBC-9.5 RBC-4.74 HGB-14.2 HCT-41.8 MCV-88
MCH-29.9 MCHC-33.9 RDW-14.3
___ 05:33PM cTropnT-<0.01
___ 05:33PM PLT COUNT-241
___ 05:33PM GLUCOSE-106* UREA N-19 CREAT-1.1 SODIUM-140
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
___ 07:00AM %HbA1c-6.3* eAG-134*
___ 07:00AM ALT(SGPT)-33 AST(SGOT)-24 CK(CPK)-78 ALK
PHOS-97 TOT BILI-0.3
=============================================================
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-9.1 RBC-4.63 Hgb-13.8* Hct-40.6
MCV-88 MCH-29.8 MCHC-34.0 RDW-14.2 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-30.3 ___
___ 07:00AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-140
K-4.1 Cl-103 HCO3-29 AnGap-12
___ 07:00AM BLOOD ALT-33 AST-24 CK(CPK)-78 AlkPhos-97
TotBili-0.3
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00AM BLOOD TSH-2.4
============================================================
IMAGING STUDIES:
___ CT HEAD W/O CONTRAST
IMPRESSION:
Focal hypodensities in the right occipital, parietoccipital
lobes and cerebellum suggest prior infarcts, at least subacute
in age, possibly old
although not necessarily chronic in all cases. MR would be
useful to assess further if needed clinically.
___ CTA HEAD AND NECK
IMPRESSION:
1. Approximately 50% narrowing of the origin of the left
internal carotid
artery secondary to mixed plaque. Atherosclerosis of left
internal carotid artery origin and of bilateral carotid siphons,
without flow-limiting stenosis.
2. High-grade stenosis of the intracranial portion of the V4
segment of the left vertebral artery proximal to ___,
spanning approximately 9 mm.
3. Small caliber and irregularity of the V4 segment of the right
vertebral artery distal to ___, with resumption of
normal caliber just proximal to confluence with the left
vertebral artery, which is likely secondary to a combination of
hypoplasia and atherosclerotic disease.
4. Small bilateral posterior cerebral arteries, presumably on
the basis of atherosclerotic disease, given the patient's age.
___ MR HEAD AND NECK
IMPRESSION:
Subacute infarcts in the bilateral occipital lobes and the
cerebellar
hemispheres. A few small foci in the right cerebellar hemisphere
may represent acute infarcts. No surrounding edema or mass
effect.
Nonspecific cerebral white matter changes and some degree of
diffuse
parenchymal volume loss. Intracranial arteries are better
assessed on the recent CT angiogram study.
Medications on Admission:
- metformin 1 tab daily, PCP asked the patient to stop this
today
- simvastatin 20 mg, PCP was planning to increase this to 80 mg
today
- ASA 81 mg
- nifedipine 30 mg daily
Discharge Medications:
1. Atorvastatin 80 mg PO HS
2. Clopidogrel 75 mg PO DAILY
3. Meclizine 12.5 mg PO Q6H:PRN Dizziness, room spinning
sensation
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Vertigo- Felt to be secondary to prior Posterior
circulation Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with posterior circulation strokes. Evaluate for
thrombosis, arterial disease, perfusion defects.
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
brain during infusion of intravenous contrast material. Images were processed
on a separate workstation with display of curved reformats, 3D volume rendered
images, and maximum intensity projection images.
DOSE: DLP: 1504.3 mGy-cm; CTDI: 84.46 mGy
COMPARISON: CT head ___.
FINDINGS:
There is scattered atherosclerotic vascular disease throughout the aortic arch
including the origins of the great vessels, without flow-limiting stenosis.
There is a common origin of the innominate artery and left common carotid
artery. There is mixed plaque in the proximal right internal carotid artery
with approximately 50% narrowing by NASCET criteria. There is minimal
atherosclerotic plaque within the proximal left internal carotid artery
without flow-limiting stenosis. The distal left cervical internal carotid
artery measures 4.9 mm. There is a tiny focus of calcified plaque within the
cervical portion of the right vertebral artery, at the C5 level. The cervical
portions of the vertebral arteries are otherwise patent without flow-limiting
stenosis. There is no evidence of dissection within the vasculature of the
neck.
The intracranial portion of the nondominant right vertebral artery at and
distal to ___ is small in caliber and irregular, resuming normal
caliber just proximal to the confluence with the left vertebral artery. This
appearance likely represents combination of hypoplasia and atherosclerotic
narrowing. There is high-grade narrowing of the intracranial portion of the
dominant left vertebral artery proximal to the ___, spanning
approximately 9 mm. Bilateral posterior cerebral arteries are unusually small
in caliber, presumably on the basis of atherosclerotic vascular disease, given
the patient's age. There is atherosclerotic vascular calcification of the
bilateral carotid siphons without flow-limiting stenosis. There is no evidence
of hemodynamically significant stenosis within the anterior circulation. There
is no evidence of aneurysm within the intracranial vasculature.
IMPRESSION:
1. Approximately 50% narrowing of the origin of the left internal carotid
artery secondary to mixed plaque. Atherosclerosis of left internal carotid
artery origin and of bilateral carotid siphons, without flow-limiting
stenosis.
2. High-grade stenosis of the intracranial portion of the V4 segment of the
left vertebral artery proximal to ___, spanning approximately 9 mm.
3. Small caliber and irregularity of the V4 segment of the right vertebral
artery distal to ___, with resumption of normal caliber just proximal
to confluence with the left vertebral artery, which is likely secondary to a
combination of hypoplasia and atherosclerotic disease.
4. Small bilateral posterior cerebral arteries, presumably on the basis of
atherosclerotic disease, given the patient's age.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with stroke // eval for pna
COMPARISON: No comparison
IMPRESSION:
The lung volumes are low. Mild cardiomegaly with atelectasis at the right lung
basis and in the retrocardiac lung regions. No larger pleural effusions. No
pneumonia, no pulmonary edema.
Radiology Report
INDICATION: ___ year old man with recent posterior circulation strokes 2
months ago, presenting with worsening dizziness // eval for acute or subacute
strokes
TECHNIQUE: MRI of the brain without IV contrast
COMPARISON: CT head, CT angiogram head and neck ___
FINDINGS:
There are multiple small foci of slightly slow diffusion in the bilateral
cerebellar hemispheres, right more than left and in the occipital lobes, right
more than left.
Most of these can represent subacute infarcts based on the signal intensity on
the DWI and FLAIR sequences and the history.
However, a few small foci in the right cerebellar hemisphere, inferomedially
demonstrate greater slow diffusion compared to the rest of the lesions and may
represent small acute infarcts.
Slightly increased FLAIR signal intensity is noted in these foci, along with
mild gyriform T1 hyperintense signal, that can relate to laminar necrosis.
There are multiple small FLAIR hyperintense foci in the cerebral white matter
in the subcortical and periventricular locations, nonspecific in appearance
and may relate to small vessel ischemic changes.
There is mild dilation of the lateral and the third ventricles along with
prominent extra-axial CSF spaces, cerebral sulci and cerebellar folia
indicating some degree of diffuse parenchymal volume loss.
A few tiny foci of negative susceptibility are noted scattered in the brain
parenchyma may relate to mineralization or micro hemorrhages.
The major intracranial arterial flow voids are noted.
The vessels are better assessed on the recent CT angiogram study.
Sella, pineal gland and the craniocervical junction regions are unremarkable.
Minimal ethmoidal mucosal thickening on both sides.
The mastoid air cells are clear.
The included orbits are unremarkable.
Bone marrow signal is unremarkable.
IMPRESSION:
Subacute infarcts in the bilateral occipital lobes and the cerebellar
hemispheres.
A few small foci in the right cerebellar hemisphere may represent acute
infarcts.
No surrounding edema or mass effect.
Nonspecific cerebral white matter changes and some degree of diffuse
parenchymal volume loss.
Intracranial arteries are better assessed on the recent CT angiogram study -
Please see details on the report.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Dizziness, Vomiting
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 98.6
heartrate: 95.0
resprate: 18.0
o2sat: 93.0
sbp: 141.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ year old ___ speaking man with a history of HTN, HLD,
lumbar stenosis, recent posterior circulation strokes with
resultant nausea and vertigo and blurry vision, presenting with
subacute worsening of symptoms over the past month.
#Vision change/Vertigo/Nausea/Vomiting: His symptoms were felt
to most likely be due to old bilateral occipital and cerebellar
infarcts, which are secondary to atherosclerosis in left ICA and
vertebral artery causing ischemic strokes. Patient underwent CT
head on ___, which showed no new infarcts. CTA performed on
___ showed narrowing and stenosis of left ICA and left vetebral
artery. Patient also underwent MRI head on ___, which showed
no new infarct or stroke, but as previous shown documented
several subacute infarcts in the PCA territory. These were felt
to be most likely secondary to his significant intracranial
atherosclerotic disease. The patient was started on plavix
(with discontinuation of aspirin) and atorvastatin 80mg (from
simvastatin 20mg). He was started on Meclizine 12.5mg q6hr PRN
dizziness with reported symptomatic improvement. Echo this
admission did not reveal a cardiogenic source of possible
embolism. Patient continued to improve during his hospital
course and was discharged home to with family after seeing
physical therapy with outpatient follow-up. A peripheral (inner
ear) source of his vertigo was considered, but not well
consistent with exam or patient history.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by nursing staff] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL =
78) - () No
5. Intensive statin therapy administered? (X) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? () Yes - (X) No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
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 [if no, reason not
discharge on anticoagulation: ____ ] - (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:
Back pain, wrist pain
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy (___)
History of Present Illness:
Ms. ___ is a ___ yo F, PMH of HTN and hypothyroidism, recently
evaluated by heme/onc for an abnormal SPEP (abnormal IgA spike)
and macrocytosis, who presents with a 1.5 wk history of back
pain. The back pain started suddenly, and may have been
associated with her changing the bed linens. She was evaluated
on ___ ___. An X-ray at that time showed degenerative
changes but no fracture. The pain has persisted over the last
week and a half. Pain is mainly central with some radiation
around both sides across her abdomen. Mainly precipitated by
activity. She has taken vicodin prescribed by her husband, who
is a ___. No radiation past the buttock. No appreciable
weakness in the legs. No bowel or bladder changes. She also
notes ___ lb weight loss since ___. Denies cp, sob,
abdominal pain.
Yesterday, while trying to sit on her bed, she missed and sat on
the floor. She braced herself with her L wrist, which is also
now painful as a result.
In the ED, initial vital signs were: 98.5 87 132/44 16 98%
Labs were notable for WBC 20 with abnormal diff (atypicals,
metas, myelos), Ht 28, Cr 1.3. CT spine showed No acute fracture
or vertebral malalignment. Patient was given morphine.
On Transfer Vitals were: 98.2 114/43 78 18 100/RA
Past Medical History:
Hypertension
Lumbar stenosis
Shingles, VZV keratitis
Hypothyroid
Macrocytosis
MGUS? abnormal M spike(IgA kappa)
Social History:
___
Family History:
No known FH of hematologic malignancies
Physical Exam:
On admission:
Vitals-98.2 114/43 78 18 100/RA
General: Well-appearing, sitting comfortably but stiffly in bed
HEENT: Normocephalic, atraumatic
Neck: No LAD, no JVD
CV: RRR, S1, S2, no m/r/g
Lungs: CTAB, no wheezing, ronchi, rales
Abdomen: soft, nontender, nondistended
GU: no Foley
Ext: warm and well perfused, 1+ bilateral edema in ankles, R
wrist edematous and tender
Spine/Back: No bruises, mild lumbar spine tenderness mainly
along spinous processes.
Neuro: CN II - XII grossly intact, ___ strength normal
On discharge:
VITALS - Tmax: 98.7 Tc: 98.3 BP: 114/64 HR: 70, RR: 19, 100% on
RA
I/Os: -1.2L
General: anxious, but otherwise well appearing in NAD
HEENT: MMM, anicteric
Neck: Supple, non-elevated JVP
CV: Normal rate, regular rhythm, no murmurs appreciated
Respiratory: Clearto auscultation
Back: TTP midline ~L1, with TTP over paraspinal muscles of
lumbar back L>R with spasm
GI: soft, NT,
Ext: 1+ edema
Neuro: Oriented x3, answers questions appropriately
Pertinent Results:
=====================
Labs:
=====================
___ 10:40AM BLOOD WBC-20.1*# RBC-2.80* Hgb-9.1* Hct-28.3*
MCV-101* MCH-32.6* MCHC-32.1 RDW-17.8* Plt ___
___ 10:40AM BLOOD Neuts-28* Bands-5 Lymphs-45* Monos-6
Eos-0 Baso-0 Atyps-3* Metas-9* Myelos-4* NRBC-6*
___ 11:40AM BLOOD ___ PTT-33.9 ___
___ 10:40AM BLOOD Glucose-113* UreaN-32* Creat-1.3* Na-145
K-4.3 Cl-102 HCO3-25 AnGap-22*
___ 06:52PM BLOOD LD(LDH)-344*
___ 06:52PM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1
Calcium-12.9* Phos-5.4* Mg-2.1
___ 05:15AM BLOOD Ret Aut-1.0*
___ 05:15AM BLOOD calTIBC-169* VitB12-978* Ferritn-402*
TRF-130*
___ 11:40AM BLOOD FreeKap-665.9* FreeLam-2.9* Fr
K/L-227.46* IgG-545* IgA-1407* IgM-23*
___ 10:40AM BLOOD PTH-6*
___ 06:52PM BLOOD PEP-ABNORMAL T
___ 11:40AM BLOOD WBC-16.3* RBC-2.40* Hgb-7.8* Hct-24.5*
MCV-102* MCH-32.5* MCHC-31.9 RDW-17.5* Plt ___
___ 05:15AM BLOOD WBC-12.1* RBC-2.44* Hgb-8.1* Hct-24.7*
MCV-101* MCH-33.2* MCHC-32.8 RDW-18.1* Plt ___
___ 05:40AM BLOOD WBC-13.5* RBC-2.37* Hgb-7.6* Hct-24.5*
MCV-103* MCH-32.0 MCHC-31.0 RDW-18.6* Plt ___
___ 10:10AM BLOOD WBC-13.5* RBC-2.36* Hgb-7.8* Hct-24.4*
MCV-103* MCH-32.8* MCHC-31.8 RDW-19.1* Plt ___
___ 07:00AM BLOOD WBC-14.1* RBC-2.21* Hgb-7.1* Hct-23.1*
MCV-104* MCH-32.3* MCHC-30.9* RDW-18.8* Plt ___
___ 12:00AM BLOOD WBC-11.3* RBC-2.08* Hgb-7.0* Hct-21.7*
MCV-104* MCH-33.4* MCHC-32.1 RDW-19.1* Plt ___
___ 12:00AM BLOOD WBC-14.1* RBC-2.51* Hgb-8.0* Hct-25.3*
MCV-101* MCH-32.1* MCHC-31.9 RDW-20.3* Plt ___
___ 12:29AM BLOOD WBC-14.7* RBC-2.16* Hgb-6.9* Hct-21.6*
MCV-100* MCH-31.9 MCHC-32.0 RDW-20.4* Plt ___
___ 02:44PM BLOOD WBC-9.3 RBC-2.62* Hgb-8.3* Hct-25.6*
MCV-98 MCH-31.6 MCHC-32.3 RDW-20.3* Plt ___
___ 12:10AM BLOOD WBC-5.9 RBC-4.04*# Hgb-12.9# Hct-39.3#
MCV-97 MCH-32.0 MCHC-32.9 RDW-20.8* Plt Ct-82*
___ 01:00PM BLOOD WBC-11.3*# RBC-2.77*# Hgb-8.8*#
Hct-26.8*# MCV-97 MCH-31.9 MCHC-32.9 RDW-21.5* Plt ___
___ 11:40AM BLOOD Neuts-29* Bands-4 ___ Monos-10
Eos-1 Baso-0 Atyps-3* Metas-7* Myelos-4* NRBC-6*
___ 05:15AM BLOOD Neuts-22* Bands-1 Lymphs-61* Monos-5
Eos-1 Baso-0 Atyps-6* Metas-1* Myelos-3* NRBC-14*
___ 05:40AM BLOOD Neuts-17* Bands-7* Lymphs-58* Monos-9
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-6* NRBC-22*
___ 10:10AM BLOOD Neuts-27* Bands-2 Lymphs-54* Monos-10
Eos-0 Baso-0 ___ Metas-5* Myelos-2* NRBC-13*
___ 07:00AM BLOOD Neuts-39* Bands-9* ___ Monos-9
Eos-1 Baso-0 Atyps-3* Metas-4* Myelos-0 NRBC-13*
___ 12:00AM BLOOD Neuts-41* Bands-12* ___ Monos-4
Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-25*
___ 12:00AM BLOOD Neuts-42* Bands-7* ___ Monos-11
Eos-0 Baso-2 ___ Metas-7* Myelos-0 NRBC-21*
___ 12:29AM BLOOD Neuts-53 Bands-1 ___ Monos-6 Eos-2
Baso-0 ___ Metas-3* Myelos-1* NRBC-8*
___ 01:00PM BLOOD Neuts-46* Bands-0 ___ Monos-10
Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-10*
___ 11:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL
___ 05:15AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr-1+ Ellipto-1+
___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 10:10AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-2+ Schisto-1+
Pencil-OCCASIONAL
___ 07:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Schisto-1+ Acantho-OCCASIONAL Ellipto-1+
___ 12:00AM BLOOD Hypochr-1+ Anisocy-3+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr-1+
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+
___ 01:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 11:40AM BLOOD ___ PTT-33.9 ___
___ 10:10AM BLOOD ___ PTT-51.6* ___
___ 07:00AM BLOOD ___ PTT-37.5* ___
___ 12:00AM BLOOD ___ PTT-52.2* ___
___ 12:00AM BLOOD ___ PTT-54.2* ___
___ 12:29AM BLOOD ___ PTT-58.9* ___
___ 12:10AM BLOOD ___ PTT-44.8* ___
___ 12:10AM BLOOD ___ PTT-44.8* ___
___ 07:00AM BLOOD CD5-DONE CD23-DONE CD138-DONE CD45-DONE
___ Kappa-DONE CD10-DONE CD13-DONE CD19-DONE
CD20-DONE Lambda-DONE
___ 07:00AM BLOOD CD34-DONE CD3%-DONE
___ 05:15AM BLOOD Ret Aut-1.0*
___ 06:20AM BLOOD Glucose-93 UreaN-34* Creat-1.5* Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 11:40AM BLOOD Glucose-96 UreaN-32* Creat-1.4* Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 05:15AM BLOOD Glucose-92 UreaN-30* Creat-1.3* Na-140
K-3.4 Cl-108 HCO3-28 AnGap-7*
___ 05:40AM BLOOD Glucose-107* UreaN-25* Creat-1.3* Na-141
K-3.7 Cl-109* HCO3-23 AnGap-13
___ 10:10AM BLOOD Glucose-84 UreaN-22* Creat-1.2* Na-139
K-3.6 Cl-109* HCO3-23 AnGap-11
___ 07:00AM BLOOD Glucose-90 UreaN-23* Creat-1.1 Na-141
K-3.7 Cl-110* HCO3-23 AnGap-12
___ 06:00PM BLOOD UreaN-21* Creat-1.0 Na-140 K-3.3 Cl-109*
HCO3-21* AnGap-13
___ 12:00AM BLOOD Glucose-144* UreaN-21* Creat-1.0 Na-141
K-3.8 Cl-110* HCO3-21* AnGap-14
___ 12:29AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-138
K-3.8 Cl-109* HCO3-21* AnGap-12
___ 12:10AM BLOOD Glucose-86 UreaN-17 Creat-0.8 Na-140
K-3.5 Cl-109* HCO3-20* AnGap-15
___ 06:20AM BLOOD AlkPhos-57
___ 10:10AM BLOOD ALT-11 AST-20 LD(LDH)-203 AlkPhos-56
TotBili-0.3
___ 07:00AM BLOOD ALT-10 AST-23 LD(LDH)-202 AlkPhos-57
TotBili-0.3
___ 12:00AM BLOOD ALT-13 AST-26 LD(LDH)-246 AlkPhos-60
TotBili-0.4
___ 12:10AM BLOOD ALT-13 AST-23 LD(___)-299* AlkPhos-56
TotBili-0.4
___ 06:20AM BLOOD Calcium-12.1* Phos-4.8* Mg-2.2
___ 11:40AM BLOOD Calcium-11.1* Phos-4.0 Mg-1.9
___ 08:44PM BLOOD Calcium-11.4*
___ 05:15AM BLOOD Calcium-10.9* Phos-3.8 Mg-1.9 Iron-59
___ 05:40AM BLOOD Calcium-10.9* Phos-3.2 Mg-1.7
___ 10:10AM BLOOD Albumin-2.7* Calcium-10.5* Phos-3.4
Mg-1.9 UricAcd-11.4*
___ 07:00AM BLOOD Albumin-2.7* Calcium-10.3 Phos-3.7 Mg-1.8
UricAcd-11.0*
___ 12:00AM BLOOD Albumin-2.7* Calcium-9.0 Phos-3.5 Mg-2.2
___ 12:00AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.5*
Mg-1.9 UricAcd-8.7*
___ 12:29AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.3
___ 12:10AM BLOOD Albumin-2.9* Calcium-7.2* Phos-1.9*
Mg-2.1 UricAcd-6.4*
___ 05:15AM BLOOD calTIBC-169* VitB12-978* Ferritn-402*
TRF-130*
___ 10:10AM BLOOD Hapto-69
___ 10:40AM BLOOD PTH-6*
___ 06:52PM BLOOD PEP-ABNORMAL T
___ 11:40AM BLOOD FreeKap-665.9* FreeLam-2.9* Fr
K/L-227.46* IgG-545* IgA-1407* IgM-23*
___ 05:15AM BLOOD b2micro-12.8*
___ 12:00AM BLOOD IgA-1185*
___ 01:00PM BLOOD WBC-11.3*# RBC-2.77*# Hgb-8.8*#
Hct-26.8*# MCV-97 MCH-31.9 MCHC-32.9 RDW-21.5* Plt ___
___ 01:00AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.9* Hct-27.7*
MCV-97 MCH-31.2 MCHC-32.2 RDW-20.8* Plt ___
___ 01:00PM BLOOD Neuts-46* Bands-0 ___ Monos-10
Eos-0 Baso-0 ___ Metas-2* Myelos-0 NRBC-10*
___ 01:00AM BLOOD Neuts-43* Bands-2 ___ Monos-7 Eos-1
Baso-0 Atyps-2* Metas-9* Myelos-2* NRBC-36*
___ 01:00AM BLOOD ___ PTT-50.1* ___
___ 01:00AM BLOOD Glucose-152* UreaN-15 Creat-0.7 Na-138
K-4.1 Cl-108 HCO3-21* AnGap-13
___ 01:00AM BLOOD ALT-10 AST-21 LD(LDH)-292* AlkPhos-62
TotBili-0.3
___ 01:00AM BLOOD Albumin-2.8* Calcium-6.7* Phos-2.0*
Mg-2.0
=====================
Micro:
=====================
Blood cultures from ___ pending
=====================
Imaging:
=====================
CT L-SPINE W/O CONTRAST Study Date of ___ 11:32 AM
IMPRESSION:
No acute fracture or vertebral malalignment.
WRIST(3 + VIEWS) RIGHT Study Date of ___ 12:08 ___
IMPRESSION: No fracture identified. Mild degenerative changes
of the first CMC and interphalangeal joints.
US ABD LIMIT, SINGLE ORGAN Study Date of ___ 8:26 AM
IMPRESSION: Spleen measures 10 cm which is in the normal range;
however, it has increased in size compared to the ultrasound on
___ when it measured 8 cm.
SKELETAL SURVEY (INCLUD LONG BONES) Study Date of ___
1:47 ___
IMPRESSION: Nonspecific generalized demineralization & fracture
of L1. These findings are nonspecific and no lytic lesions of
classic multiple myeloma.
MRI L-spine:
IMPRESSION:
1. Compression fracture deformity of L1 vertebral body with
nearly 50% height loss at the anterior aspect, without evidence
of enhancement or significant edema, raising the possibility of
subacute vertebral body compression fracture versus
devascularization of the vertebral body or avascular necrosis of
this vertebral body segment. No evidence of retropulsion into
the spinal canal, cord or conus compression. The appearance is
not typical for metastatic disease.
2. Diffuse low T1 signal throughout the lumbar spine, most
consistent with diffuse bone marrow hyperplasia or bone marrow
infiltration.
3. Moderate multilevel spondylosis, most severe at L4-L5, along
with grade 1 anterolisthesis at this level, resulting in
moderate spinal canal narrowing which appear grossly stable
compared to prior study of ___. There is moderate
to severe left and mild right neural foraminal narrowing at this
level.
PET CT SCAN:
IMPRESSION: 1. FDG-avid compression fracture of L1.
FDG-avidity may relate to pre-existing disease or may be due to
the compression fracture itself. Acute fractures are FDG-avid
while there is an inflammatory response to the fracture.
2. No there other sites of abnormal FDG avidity in the body.
(Note the entire body from skull vertex to toes was surveyed.)
U/S of right upper extremity:
IMPRESSION:
1. Right brachial vein DVT.
2. Right basilic vein PICC without basilic, axillary, or
subclavian vein
thrombus.
Standing L-spine X-ray:
FINDINGS: There is a similar moderate-to-severe compression
fracture of the L1 vertebral body, potentially with minimally
increased in height loss since the prior study. There is clear
evidence for substantial retropulsion. Associated with the
fracture, however, a slight kyphotic angulation corresponding to
the T12- L1 level without substantial subluxations. The L4-L5
and T11-T12 interspaces are moderately narrowed. Patchy
vascular calcifications are preserved.
IMPRESSION: Moderate-to-severe L1 compression deformity,
similar to perhaps minimally increased.
___:
IMPRESSION:
No evidence of deep vein thrombosis in the bilateral lower
extremities.
=====================
Pathology:
=====================
Tissue: BONE MARROW, BIOPSY, CORE Procedure Date of ___:
pending
PATHOLOGIC DIAGNOSIS:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY
IMMUNOSECRETORY
NEOPLASM, SEE NOTE.
Note: By immunohistochemistry neoplastic cells are
immunoreactive for
CD20, MUM1, CD138, and are IgA kappa restricted (IgG, IgM and
Lambda
light chains are negative). In addition cells are immunoreactive
for
CD79a and PAX5 (BSAP) (dim) and negative for BCL1. CD3 and CD5
highlights scattered small lymphocytes. The proliferation
fraction is
high, in some places reaching more than 50%. The differential
diagnosis
is restricted to lymphoplasmacytic lymphoma versus round cell
myeloma,
the latter of which is often CD20 and BCL1 positive. The
morphological
features, lack of BCL1 expression, expression of PAX5 and
absence of
lytic lesions in the setting of extensive bone marrow
infiltration, all
seem to favor the diagnosis of lymphoplasmacytic lymphoma.
Unfortunately, marrow aspirate was unyielding "dry tap"
precluding
examination of a ___ stained bone marrow smear or
obtaining
cytogenetic studies, which would have greatly facilitated the
evaluation of this neoplasm.
Of note, flow cytometry of peripheral blood demonstrated an
apparently
unrelated clonal population of CD5 positive lambda-restricted B
lymphocytes.
The presence of nucleated red blood cells and immature
neutrophils in
the peripheral blood is consistent with a myelophthisis process
most
likely due to the highly proliferative neoplasm in the marrow,
as
demonstrated by ___ staining and the presence of numerous
mitoses.
MICROSCOPIC DESCRIPTION.
PERIPHERAL BLOOD SMEAR:
The smear is adequate for evaluation. Erythrocytes are
decreased,
normochromic, and macrocytic and have marked anisopoikilocytosis
including macroovalocytes elliptocytes and dacrocytes. The
white blood
cell count is slightly increased. Plasmacytoid lymphocytes and
rare
plasma cells are seen. Hypolobated and pseudo Pelger-Huet
neutrophils
are seen. Rare blasts are seen. Platelet count appears normal.
Many
large and giant platelets are seen. A 200 cell differential
shows 36%
neutrophils, 46% lymphocytes, 7% monocytes, 1% basophils, 6%
myelocytes, 4% metamyelocytes, and 8 nucleated RBCs per 100
nucleated
cells.
ASPIRATE SMEAR:
Not provided (dry tap).
CLOT SECTION and BIOPSY SLIDES:
The core biopsy material is adequate for evaluation. It
consists of a
1.2 cm core biopsy of trabecular marrow and cortical bone with a
cellularity of more than 95%. There is a wall-to-wall
infiltrate of
mononuclear cells comprising most of the cellularity. Majority
of the
neoplastic cells have atypical morphology with round nuclei and
moderate amounts of cytoplasm. Nuclei are positioned centrally,
not
eccentricaly. Numerous mitoses are seen. Abundant ___ and
___
bodies are seen in some of the cells. Scant background maturing
hematopoietic elements are seen. Rare megakaryocytes are seen.
The
clot section show similar findings.
ADDITIONAL STUDIES:
Flow cytometry: See separate report ___
Cytogenetics: not submitted (dry tap)
By immunohistochemistry staining the neoplastic cells are
positive for
CD20, CD138, MUM1 and are IgA Kappa restricted (IgG, IgM, and
Lambda
are negative). Bcl-1 is negative. focally proliferation
fraction by
___-67 staining is >50%. This correlates well with high mitotic
rate by
morphology. CD3 and CD5 highlight scattered T-cells. Lack of
staining
in other areas of the biopsy may be artifactual due to
decalcification
which is known to decrease reactivity to the K1-67 antibody.
SPECIMEN(S) SUBMITTED:
1. BONE MARROW, BIOPSY, CORE
2. PERIPHERAL BLOOD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. HYDROcodone-acetaminophen ___ mg oral ___ tabs q4-6h prn
p;ain
4. Potassium Chloride 20 mEq PO DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Cyanocobalamin 1000 mcg IM/SC EVERY MONTH
7. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Acyclovir 400 mg PO Q8H
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet extended release 12
hr(s) by mouth every twelve (12) hours Disp #*60 Tablet
Refills:*0
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Cyanocobalamin 1000 mcg IM/SC EVERY MONTH
11. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe
breakthrough pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
13. Allopurinol ___ mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
16. Acetaminophen 1000 mg PO Q8H:PRN pain
17. Lorazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
18. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: lymphoplasmacytic lymphoma
Secondary: L1 compression fracture, hypercalcemia, acute kidney
injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Wrist injury, status post fall.
COMPARISON: None available.
FINDINGS: Four views of the right wrist, though the navicular view is
suboptimal, excluding majority of the scaphoid. No fracture identified.
There is normal alignment. There are mild degenerative changes with joint
space narrowing at the first carpometacarpal and first interphalangeal joint.
No abnormal soft tissue calcification. Soft tissue swelling is noted about the
dorsum of the wrist.
IMPRESSION: No fracture identified. Mild degenerative changes of the first
CMC and interphalangeal joints.
Radiology Report
HISTORY: Chronic degenerative disease, now with acute low back pain status
post fall last night.
COMPARISON: Comparison is made with MR ___ from ___ and
___ radiographs from ___.
TECHNIQUE: Helical axial MDCT sections were obtained from the lumbar spine.
Reformatted images in sagittal and coronal axes were obtained.
FINDINGS:
There is no acute fracture or vertebral malalignment. There is generalized
bony demineralization. Moderate to severe multilevel degenerative changes are
seen throughout the ___, most prominent at the L4-5 disc space with
posterior disc bulge, vertebral disc space height loss, endplate sclerosis,
and vacuum disc phenomenon. Mild anterolisthesis of L4 over L5 is again seen.
Compression deformity of L1 is again seen, similar to ___ radiographs from
4 days prior but new since MR from ___. CT is not able to provide
intrathecal detail comparable to MRI, but the visualized outline of the thecal
sac appears unremarkable. Atherosclerotic disease in is seen in the abdominal
aorta. Otherwise, the visualized intra-abdominal organs are unremarkable.
IMPRESSION:
No acute fracture or vertebral malalignment.
Radiology Report
INDICATION: Back pain and hematologic abnormalities, possible MDS, MPD;
assess for splenomegaly.
COMPARISON: Abdominal ultrasound on ___.
FINDINGS: The spleen is normal in echotexture and measures 10 cm. On prior
ultrasound of ___ it measured 8 cm. No focal lesions are seen within
the spleen. There is a trace left pleural effusion.
IMPRESSION: Spleen measures 10 cm which is in the normal range; however, it
has increased in size compared to the ultrasound on ___ when it
measured 8 cm.
Radiology Report
HISTORY: ? multiple myeloma, renal failure and hypercalcemia.
This exam consists of 12 radiographs of the calvarium, thoracic and lumbar
spine, pelvis, and proximal humeri and femurs. There is generalized
demineralization with a biconcave L1 body and probable associated anterior
fracture. No other fracture is identified. There is a mottled appearance to
the calvarium and to less extent femurs and humeri with no discrete lytic
lesion. The hips and SI joints are normal and symmetric.
IMPRESSION: Nonspecific generalized demineralization & fracture of L1. These
findings are nonspecific and no lytic lesions of classic multiple myeloma.
Radiology Report
HISTORY: ___ woman with presumed multiple fluid signal intensity is
very cm structures throughout the kidneys. Myeloma, with L1 compression
fracture. Evaluate for spinal canal narrowing, cord impingement.
TECHNIQUE: Multiplanar, multisequence MRI of the lumbar spine was performed
before and after intravenous contrast administration.
COMPARISON: CT lumbar spine without contrast ___. Skeletal
survey ___. MRI lumbar spine ___.
FINDINGS:
Again seen is a compression deformity of L1 vertebral body, with approximately
50% height loss anteriorly, with a wedge compression appearance. These
findings are stable compared to CT lumbar spine from ___. There
is no evidence of significant retropulsion into the spinal canal. The
compressed portion of the vertebral body, which is the anterior on half of L1,
demonstrates T2 and STIR hypointensity with T1 isointensity. Post-contrast
imaging demonstrates hypoenhancement of the compressed portion, as wells as
minimal edema, raising the possibility of devascularization of the vertebral
body or avascular necrosis of this segment.
There is grade 1 (3 mm) anterolisthesis of L4 on L5. There is also grade 1 (2
mm) anterolisthesis of T12 on L1. The other vertebral body heights are
preserved. There is diffuse low T1 signal throughout the lumbar spine, most
consistent with diffuse bone marrow hyperplasia or bone marrow infiltration.
There is a focus of T1 and T2 hyperintensity within the posterior aspect of
the T11 vertebral body, not seen on fat saturated images, and most consistent
with vertebral hemangioma. The a conus medullaris demonstrates normal signal
intensity and morphology and terminates at the level of L2. There is no
evidence of cord or conus compression. There is no evidence of abnormal
enhancement within the spinal canal or other vertebral bodies.
There is generalized ligamentum flavum thickening and facet arthropathy.
T11-T12, T12-L1, and L1-L2: There is minimal diffuse disc bulge, without
spinal canal or neural foraminal narrowing.
L2-L3, L3-L4: There is mild diffuse disc bulge, facet arthropathy, ligamentum
flavum thickening and fluid within the facet joints, resulting in mild
subarticular zone narrowing with crowding of the traversing nerve roots but no
significant nerve root compression. There is no spinal canal or neural
foraminal narrowing.
L4-L5: There is grade 1 anterolisthesis of L4 on L5 with uncovering of the
posterior superior aspect of the intervertebral disc, as well as severe facet
arthropathy and moderate ligamentum flavum thickening, resulting in moderate
spinal canal narrowing and subarticular zone narrowing. Subarticular zone
narrowing resulting in crowding of the bilateral traversing L5 nerve roots.
There is moderate to severe left and mild right neural foraminal narrowing.
Findings appear grossly stable compared to ___.
L5-S1: There is mild diffuse disc bulge, facet arthropathy and ligamentum
flavum thickening, without significant spinal canal or neural foraminal
narrowing.
Note is made of a prominent gallbladder, measuring approximately 5.4 x 4.4 cm.
There are multiple pericentimeter fluid signal intensity structures within
both kidneys.
IMPRESSION:
1. Compression fracture deformity of L1 vertebral body with nearly 50% height
loss at the anterior aspect, without evidence of enhancement or significant
edema, raising the possibility of subacute vertebral body compression fracture
versus devascularization of the vertebral body or avascular necrosis of this
vertebral body segment. No evidence of retropulsion into the spinal canal,
cord or conus compression. The appearance is not typical for metastatic
disease.
2. Diffuse low T1 signal throughout the lumbar spine, most consistent with
diffuse bone marrow hyperplasia or bone marrow infiltration.
3. Moderate multilevel spondylosis, most severe at L4-L5, along with grade 1
anterolisthesis at this level, resulting in moderate spinal canal narrowing
which appear grossly stable compared to prior study of ___.
There is moderate to severe left and mild right neural foraminal narrowing at
this level.
Dr. ___ these findings by phone with Dr. ___ at 03:45 on
___.
Radiology Report
HISTORY: ___ female with new right-sided PICC placement.
COMPARISON: Radiograph of the chest dated ___.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates well expanded clear
lungs. The cardiomediastinal and hilar contours are unremarkable. There is
no pneumothorax or consolidation. Small bilateral pleural effusions are
slightly improved from the prior study. The right-sided PICC line courses up
into the neck and ends outside the field of view of this radiograph.
IMPRESSION:
The right-sided PICC line courses up into the neck and ends outside the field
of view of this radiograph.
COMMENTS: These findings were discussed with ___ (PICC nurse) by
Dr. ___ telephone at 5:09pm on ___, 30 minutes after
discovery.
Radiology Report
INDICATION: Malpositioned right PICC.
PHYSICIANS: Dr. ___ (fellow) and Dr. ___ (attending).
ANESTHESIA: None.
CONTRAST: None.
PROCEDURE DETAILS: The patient was brought to the angiography suite and
placed supine on the imaging table. The preprocedure timeout was performed as
per ___ protocol. A scout fluorscopic image demonstrates an indwelling right
PICC extending into the internal jugular vein. One of the lumens of the
indwelling right dual-lumen PICC was uncapped and cleaned with alcohol. The
lumen aspirated easily and 10 cc sterile saline was injected with moderate
force under fluoroscopy. The tip migrated from the right internal jugular vein
into the distal SVC without difficulty. Final spot fluoroscopic image
demonstrates the PICC in good position with the tip in the distal SVC. The
patient tolerated the procedure well without complications.
IMPRESSION: Successful repositioning of a right PICC. The tip is in the SVC.
Radiology Report
HISTORY: Status post right arm PICC with increasing swelling.
COMPARISON: None.
FINDINGS:
Grayscale, color, and spectral Doppler evaluation was performed of the right
upper extremity veins. There is normal phasicity of the subclavian veins
bilaterally. A right upper extremity PICC enters the basilic vein and courses
through the right axillary and subclavian veins. One of the paired brachial
veins contains echogenic thrombus, is noncompressible, and demonstrates no
flow on color or spectral Doppler evaluation. The other brachial vein,
basilic vein (which contains the PICC), cephalic vein, axillary vein,
subclavian vein, and right internal jugular vein demonstrate normal
compression.
IMPRESSION:
1. Right brachial vein DVT.
2. Right basilic vein PICC without basilic, axillary, or subclavian vein
thrombus.
Findings were communicated via phone call by Dr. ___ to Dr. ___
___ on ___ at 1241 ___.
Radiology Report
RADIOGRAPHS OF THE LUMBAR SPINE
HISTORY: Newly diagnosed multiple myeloma with L1 compression fracture.
COMPARISONS: MR from ___ and skeletal survey from ___.
TECHNIQUE: Lumbar spine, AP and lateral, standing views with a brace.
FINDINGS: There is a similar moderate-to-severe compression fracture of the
L1 vertebral body, potentially with minimally increased in height loss since
the prior study. There is clear evidence for substantial retropulsion.
Associated with the fracture, however, a slight kyphotic angulation
corresponding to the T12- L1 level without substantial subluxations. The
L4-L5 and T11-T12 interspaces are moderately narrowed. Patchy vascular
calcifications are preserved.
IMPRESSION: Moderate-to-severe L1 compression deformity, similar to perhaps
minimally increased.
Radiology Report
HISTORY: Bilateral lower extremity swelling.
TECHNIQUE: Grayscale, color Doppler and spectral Doppler evaluation was
performed of the bilateral lower extremity veins.
COMPARISON: Comparison is made to lower extremity Doppler ultrasound dated ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, proximal femoral, mid femoral, distal 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 vein thrombosis in the bilateral lower extremities.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Dizziness
Diagnosed with LUMBAGO, ANEMIA NOS, HYPERTENSION NOS, HYPOTHYROIDISM NOS
temperature: 98.5
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 44.0
level of pain: 10
level of acuity: 2.0 | Mrs. ___ is a ___ yo F with a recent history of hematologic
abnormalities including macrocytosis and an IgA M-spike who
presents with 1.5 week history of back pain, 4 month history of
___ lb. unintentional weight loss, ___, and hypercalcemia,
concerning for hematologic malignancy.
#Lymphoplasmacytic lymphoma vs round cell myeloma: Pt with
history of MGUS (IgA elevated at 580 in ___ and
unintentional weight loss of 25 lbs over past 3 months
concerning for malignancy. Definite lymphocytosis with left
shift in myeloid lineages. Also with macrocytic anemia. Pt
presented with significantly elevated IgA from prior (1407) and
elevated free kappa and free kappa/free lambda light chains.
There was concern for MM in particular, given hypercalcemia,
anemia, and back pain. BM biopsy (performed on ___ was a dry
tap that showed 95% cellularity all packed with cells that are
atypical for plasma cells because they are more lymphoid looking
either lymphoplasmacytic lymphoma or round cell myeloma. Pt was
transferred to the Bone Marrow Transplant service. The final
bone marrow biopsy result was pending prior to discharge but
preliminary findings were most consistent with lymphoplasmacytic
lymphoma. Patient was treated with velcade, dexamethasone, and
cytoxan (first day = ___ and will continue to receive
treatment in the outpatient setting.
#Back pain: Imaging showed a subacute compression fracture at L1
but did not show lytic lesions or plasmacytomas typical for MM.
There was no cord compression identified on imaging. Pt was
treated with tylenol, oxycodone, oxycontin, and lidocaine patch.
She was evaluated by orthopedic spine surgery who recommended a
brace when out of bed. She had a standing X-ray on ___ that
showed kyphosis and ortho spine advised that a kyphoplasty would
be indicated to help with her pain and mobility. Patient
preferred to hold off on kyphoplasty given her acute illness and
start of chemotherapy. She was discharged on oxycontin 10 mg PO
BID with oxycodone for breakthrough pain and a lidocaine patch.
#Hypercalcemia: Patient initially presented with calcum of 12.9.
Likely due to hematologic malignancy. PTH is 6, which supports
non-hyperparathyroid etiologies. She has no neurological
symptoms. She was treated with IV fluids and received a dose of
pamidronate 90 mg IV on ___ and her calcium decreased to within
normal limits prior to discharge.
___: Cr 1.3 at presentation, baseline 0.7. FENa of 0.3%.
Creatine initially remained elevated despite IV fluids but
decreased to her baseline of 0.7 prior to discharge.
#Macrocytic anemia. She is receiving Vitamin B12, and has no
apparent reasons for having folate or thiamine deficiency,
anemia is likely related to underlying hematologic malignancy.
Patient was transfused 2 units of pRBCs during her
hospitalization which she tolerated well.
#Bilateral lower extremity swelling: Patient had bilateral lower
extremity swelling. ___ of bilateral lower extremities were
negative for DVTs. She received a dose of 10 mg IV lasix on ___
and was continued home lasix 20 mg PO daily thereafter and her
swelling improved prior to discharge.
#Right upper extremity swelling: Patient had right PICC placed
on ___ and had new swelling of RUE on ___. U/S revealed right
brachial vein DVT. She was started on lovenox 80 mg SC Q12H.
#Wrist pain: ___ to fall. No fractures on xray. Pain improved
with conservative therapy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
left-sided chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of metastatic pulmonary sarcoma,
HFpEF, HTN/HLD, and essential
tremor who initially presented to ___ for acute onset
chest pain and was subsequently transferred to ___ after he
was found
to have a new pneumothorax and pleural effusion.
Patient says that after awaking this AM ~6AM, he felt 'terrible'
L-sided chest pain, tearing in quality, max ___ in severity.
The pain was non-radiating. High intensity pain lasted for
~.5h,
then slowly reducing for .5h. Patient denies any associated SOB
or palpitations, no lightheadedness or dizziness. Given the
severity of his pain, patient was brought to ___ for
evaluation.
At ___, patient was chest pain free on arrival. He was
noted to be dyspneic getting into the ED. ECG similar to prior,
trop <.01 x1. CXR showed a small left PTX and pleural effusion.
He was transferred to ___ for further management.
Past Medical History:
Metastatic Pulmonary Sarcoma
HFpEF
Pulmonary HTN
Moderate AR
Essential tremor
HTN
HLD
Glaucoma
Hypothyroidsm
Social History:
___
Family History:
Father: colon cancer
Physical Exam:
Exam on Admission:
===============
VS: 97.6 ___ 20 97 2L
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP clear
with MMM.
NECK: Prominent carotid pulse, no JVP elevation.
HEART: RRR, S1/S2, ___ SEM heard throughout the precordium, no
gallops or rubs.
LUNGS: Relative decrease in breath sounds over L lung, otherwise
clear to auscultation.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Slightly cool. Trace pretibial edema b/l.
PULSES: 1+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
Exam on Discharge:
===============
VS: T 98 BP 100/59 HR 67 RR 20 SO2 93% on room air
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, OP clear
with MMM, non-tender posterior cervical lymphadenopathy on the L
NECK: Prominent carotid pulse, no JVP elevation.
HEART: RRR, S1/S2, ___ SEM heard throughout the precordium with
maximum intensity at ___ R ICS, no gallops or rubs.
LUNGS: Vesicular lung sounds bilaterlly. No adventitious lung
sounds.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Slightly cool. Trace pretibial edema b/l.
PULSES: 1+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
Pertinent Results:
Labs on Admission:
==============
___ 06:40AM BLOOD WBC-6.3 RBC-3.99* Hgb-12.6* Hct-39.5*
MCV-99* MCH-31.6 MCHC-31.9* RDW-14.1 RDWSD-50.9* Plt ___
___ 06:40AM BLOOD Glucose-85 UreaN-28* Creat-0.8 Na-145
K-3.8 Cl-105 HCO3-27 AnGap-13
___ 06:40AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
Labs on Discharge:
==============
___ 08:05AM BLOOD WBC-5.6 RBC-3.99* Hgb-12.7* Hct-39.6*
MCV-99* MCH-31.8 MCHC-32.1 RDW-14.0 RDWSD-50.8* Plt ___
Imaging:
=======
___ CT CHEST W/O CONTRAST:
1. Numerous metastatic lesions throughout the lungs with the
largest occurring
in the bases bilaterally. The largest lesion in the left face
measures up to
10.8 cm and is associated with obstruction of subsegmental left
lower lobe
bronchi. Central hypodensity of this lesion and a second lesion
in the left
lower lobe is suggestive of necrosis.
2. Small left pneumothorax and moderate layering left pleural
effusion.
3. Borderline aneurysmal dilation of the ascending thoracic
aorta measuring up
to 5 cm.
___ CHEST (PORTABLE AP):
In comparison with the study of ___, there is little change
in the
extensive multiple lung masses of varying size, consistent with
widespread
metastatic disease. Little overall change in the degree of
small left apical
pneumothorax.
Remainder the study is unchanged.
___ CHEST (PA & LAT):
In comparison with the earlier study of this date, there is
little overall
change in the diffuse bilateral pulmonary metastases. The
degree of
pneumothorax is stable on the left. A line mimicking lateral
pneumothorax
represents merely a skin fold.
___ CHEST (PA & LAT):
Since ___, there has been little change multiple pulmonary
metastases some
quite large. The small left apical pneumothorax is no longer
appreciated.
Left lower lobe collapse and moderate left pleural effusion are
unchanged.
The aorta is tortuous with mild calcification, unchanged. The
cardiac border
is obscured, but ___ of the cardiac silhouette have
decreased.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with PMHx sarcoma, wedge resection now p/w SOB w/ pneumo on
xray at ___// Effusion/pneumothorax?
TECHNIQUE: MD CT images were obtained through the chest without the
administration of IV contrast. Coronal sagittal reformats were provided.
DOSE: Total DLP (Body) = 189 mGy-cm.
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are prominent supraclavicular
lymph nodes.
UPPER ABDOMEN: Partially visualized cystic lesion in the upper abdomen in the
expected location of the right kidney likely represents a simple right renal
cyst.
MEDIASTINUM: There are numerous prominent paratracheal lymph nodes.
HILA: There are prominent right-sided hilar lymph nodes.
HEART and PERICARDIUM: Heart appears mildly enlarged. There is no pericardial
effusion.
PLEURA: There is a small left pneumothorax. There is moderately left pleural
effusion.
LUNG:
1. PARENCHYMA: There are numerous metastatic lesions throughout both lungs.
The largest occur in the bases bilaterally. The largest on the right is
subpleural in the right lower lobe and measures approximately 5.0 x 5.0 cm.
The largest at the left base measures approximately 10.8 x 6.5 cm and appears
centrally hypodense, suggesting necrosis. The second largest lesion also in
the base of the left lung also appears slightly hypodense.
2. AIRWAYS: Left lower lobe subsegmental bronchi appear obstructed by large
left lower lobe mass.
3. VESSELS: There is borderline aneurysmal dilation of the ascending aorta
which measures up to 4.9 cm. There is significant atherosclerotic
calcification of the aortic arch and descending thoracic aorta
CHEST CAGE: No evidence of fractures or aggressive osseous lesions.
IMPRESSION:
1. Numerous metastatic lesions throughout the lungs with the largest occurring
in the bases bilaterally. The largest lesion in the left face measures up to
10.8 cm and is associated with obstruction of subsegmental left lower lobe
bronchi. Central hypodensity of this lesion and a second lesion in the left
lower lobe is suggestive of necrosis.
2. Small left pneumothorax and moderate layering left pleural effusion.
3. Borderline aneurysmal dilation of the ascending thoracic aorta measuring up
to 5 cm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with lung sarcoma, HFpEF, pulmHTN, and HTN/HLD
who presents with CP, found to have small pneumothorax.// PTX evaluation
IMPRESSION:
In comparison with the study of ___, there is little change in the
extensive multiple lung masses of varying size, consistent with widespread
metastatic disease. Little overall change in the degree of small left apical
pneumothorax.
Remainder the study is unchanged.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pneumo// Pneumothorax progression?
IMPRESSION:
In comparison with the earlier study of this date, there is little overall
change in the diffuse bilateral pulmonary metastases. The degree of
pneumothorax is stable on the left. A line mimicking lateral pneumothorax
represents merely a skin fold.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ YO with metastatic pulmonary sarcoma and new L PTX. // L PTX
resolved?
COMPARISON: Chest radiographs from ___ through ___
FINDINGS:
PA and lateral views of the chest provided.
Since ___, there has been little change multiple pulmonary metastases some
quite large. The small left apical pneumothorax is no longer appreciated.
Left lower lobe collapse and moderate left pleural effusion are unchanged.
The aorta is tortuous with mild calcification, unchanged. The cardiac border
is obscured, but ___ of the cardiac silhouette have decreased.
IMPRESSION:
1. There is no pneumothorax. No other significant change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumothorax, Transfer
Diagnosed with Pneumothorax, unspecified
temperature: 97.5
heartrate: 70.0
resprate: 22.0
o2sat: 97.0
sbp: 134.0
dbp: 72.0
level of pain: UA
level of acuity: 2.0 | ___ is a ___ with history of metastatic
pulmonary sarcoma, HFpEF, HTN/HLD, and essential tremor who
initially presented to ___ for acute onset chest pain
and was
subsequently transferred to ___ after he was found to have a
left pneumothorax.
Acute Issues
============
# Pneumothorax
Mr. ___ had presented to ___ with left-sided chest
pain. The left-sided pneumothorax was the most likely cause of
patient's chest pain. Troponins were negative a ___.
Thoracic surgery evaluated the patient in ED and there was no
emergent indication for chest tube placement. Mr. ___ was
treated with high flow oxygen for a day and the pneumothorax as
well as the chest pain completely resolved.
# metastatic pulmonary sarcoma
We touch based with the patient's oncologist Dr. ___
___. She had last seen the patient ___ years ago. At that
point Mr. ___ wished not to come in anymore for follow up but
was offered to be seen anytime if he wished so.
# Goals of care: Goals of cares were clarified with Mr. ___
alone and later in the presence of his son. Mr. ___ stated
that he would not want to receive CPR in the event of cardiac
arrest. He also made clear that he would not want endotracheal
intubation/invasive mechanical ventilation for himself.
Chronic Issues
==============
# HFpEF (LVEF >55%)
Mr. ___ did not appear volume overloaded on exam. Continued
home furosemide 80mg qd (recently increased last week by
cardiologist)
# Hypertension
Continued home nifedipine 60mg qd, valsartan 320mg qd
# Hypothyroidism
Continued home levothyroxine 25mcg qd
# Essential tremor
Continued home phenobarbital 60mg qHS
# Dyslipidemia
Continued home simvastatin 10mg qHS
# Glaucoma
Continued home eye gtt
# Insomnia/anxiety
Continued home lorazepam .5mg qHS PRN, consider alternative
agent given advanced again
TRANSITIONAL ISSUES
===================
[] Consider referral back to ___ with Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Ciprofloxacin Hcl / Warfarin / Cozaar /
Norvasc / Lisinopril / Rosuvastatin / Flexeril / Uloric
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ h/o HFrEF with EF 20% (___), asthma, CAD s/p PCI to AD
& ramus in ___, mild AR and MR, CKD (b/l Cr~1.7-2.0),
hypertension, GERD, and OSA who presents with chest pain, cough,
and difficulty breathing. Chest pain began yesterday (___)
with cough "all night," on left sternal border. He called his
PCP ___ prescribed guaifenesin with codeine cough
syrup. The medication helped him stop coughing as much, but he
had the cough all throughout the night. He notes associated
nasal congestion and malaise in the same time period. In the ED,
his chest pain was ___, localized to 6 cm lateral to the
sternum on the left at the level of the ___ ICS. The pain
worsened with breathing or coughing, and if he pressed on the
area the pain is recreated. No radiation. Feels that "may have
pulled a muscle." Patient has had ___ MIs in the past and said
pain feels similar to those episodes. Pt has difficulty
breathing. Pt has had cough for 5 days, but denies hemoptysis.
Of note, he was recently admitted from ___ to ___ for
chest pain found to be negative from a cardiac/pulmonary
perspective as EKG, troponins, ___, and VQ scan were
negative. CP was thought ___ GERD and he was discharged on
ranitidine. His course was complicated by mild fluid overload
in the setting of HFrEF, aspiration pneumonia, SVT with HR's in
the 150's in the setting of acute infection, and ___. His ___
and ___ diuretic were stopped with improvement in the ___. He
was treated with a 7 day course of cefpodoxime and azithromycin
for aspiration pneumonia. His home metoprolol was increased and
his heart rates improved.
Past Medical History:
- Asthma/COPD with restrictive features (FEV1 81% predicted,
FEV1/FVC 106% ___ PFTs),
- Coronary artery disease s/p ___ to LAD and Ramus ___
patent with 40% ramus, 20% OM1 on cath ___
-HFrEF (EF 20% ___, Ischemic/non-ischemic Cardiomyopathy.
- Aortic regurgitation - mild ___ echo)
- Mitral regurgiattion - mild-moderate ___ echo)
- Dilated ascending aorta - mild ___ echo)
- Chronic renal failure (creatinine 1.7-1.9mg/dl)
- Gout and CPPD on chronic prednisone
- GERD
- Obstructive sleep apnea
- Hernia repair (epigastric ___ inguinal ___
- Cataracts, bilateral
- Lower back pain
- Osteoarthritis
- Hemorrhoidal surgery
- Childhood polio
- Rhabdomyolysis - rosuvastatin
Social History:
___
Family History:
Parents are both deceased. He has no biologic children. He had
17 siblings but only a sister (___, dialysis) and brother (___,
kidney problems) are still alive.
Physical Exam:
DISCHARGE PHYSICAL EXAM
Vitals: ___ 0753 Temp: 98.3 PO BP: 124/84 HR: 64 RR: 16 O2
sat: 99% O2 Ra
I/Os: ___
GENERAL: Alert and oriented, somnolent, but interactive with
exam.
HEENT:PERRLA, poor dentition, oropharynx non-erythematous.
NECK: No lymphadenopathy. Neck veins difficult to assess for
JVD.
CARDIAC: S1, S2, no m/g/r
LUNGS: Breath sounds decreased in bases bilaterally. Mild
crackling at bases. Not using accessory muscles while resting in
bed. Upper airway noises on inspiration and expiration.
ABDOMEN: Tympanic abdomen. Non-tender, non-distended.
EXTREMITIES: Minimal edema in bilateral lower extremities.
NEURO: Moving all four extremities. No focal deficits.
Pertinent Results:
ADMISSION LABS
___ 08:50AM CK-MB-10 proBNP-5130*
___ 08:50AM cTropnT-0.08*
___ 08:50AM WBC-8.0 RBC-3.73* HGB-11.6* HCT-37.2*
MCV-100* MCH-31.1 MCHC-31.2* RDW-14.3 RDWSD-52.5*
___ 12:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
DISCAHRGE LABS
___ 07:20AM BLOOD WBC-6.7 RBC-3.72* Hgb-11.6* Hct-36.9*
MCV-99* MCH-31.2 MCHC-31.4* RDW-14.3 RDWSD-52.1* Plt ___
___ 08:55AM BLOOD Glucose-193* UreaN-48* Creat-2.2* Na-141
K-4.4 Cl-98 HCO3-33* AnGap-10
___ 08:27AM BLOOD ALT-33 AST-28 LD(LDH)-221 CK(CPK)-758*
AlkPhos-56 TotBili-0.6
___ 11:14PM BLOOD CK-MB-5 cTropnT-0.21*
___ 08:55AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
IMAGING/STUDIES:
CARDIAC PERFUSION REST ___:
1. Severe, large resting perfusion defect involving the RCA
territory.
2. Small, severe resting perfusion defect involving the LAD
territory.
PA/Lat CXR ___: There are bilateral lower lobe opacities,
likely atelectasis; however, pneumonia cannot be completely
excluded. There is a stable small right effusion. The heart is
enlarged, similar to previous. The aorta is tortuous. The bones
are diffusely osteopenic. There is scoliosis and degenerative
changes of the spine. Degenerative changes are seen in the
shoulder.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Benzonatate 100 mg PO TID:PRN cough
6. Cetirizine 10 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 500 mg PO DAILY
12. LORazepam 0.5 mg PO QHS:PRN leg twitching
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. PredniSONE 5 mg PO DAILY
17. Simethicone 80-160 mg PO QID:PRN bloating, gas
18. Spironolactone 25 mg PO 3X/WEEK (___)
19. Vitamin D 1000 UNIT PO DAILY
20. Ranitidine 150 mg PO DAILY
21. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
22. Calcitriol 0.25 mcg PO TWICE A WEEK
23. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
24. codeine-guaifenesin ___ mg/5 mL oral TID:PRN
Discharge Medications:
1. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1
tablet(s) by mouth q24h Disp #*30 Tablet Refills:*0
3. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
4. Valsartan 40 mg PO DAILY RX *valsartan 40 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
7. Gabapentin 200 mg PO DAILY
8. Acetaminophen 1000 mg PO TID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
10. Aspirin 81 mg PO DAILY
11. Benzonatate 100 mg PO TID:PRN cough
12. Calcitriol 0.25 mcg PO TWICE A WEEK
13. Cetirizine 10 mg PO DAILY
14. Clopidogrel 75 mg PO DAILY
15. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
16. Docusate Sodium 100 mg PO BID:PRN constipation
17. Fluticasone Propionate NASAL 1 SPRY NU DAILY
18. FoLIC Acid 1 mg PO DAILY
19. LORazepam 0.5 mg PO QHS:PRN leg twitching
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Multivitamins 1 TAB PO DAILY
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. PredniSONE 5 mg PO DAILY
24. Ranitidine 150 mg PO DAILY
25. Simethicone 80-160 mg PO QID:PRN bloating, gas
26. Vitamin D 1000 UNIT PO DAILY
27. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until your doctor says to
28. HELD- Spironolactone 25 mg PO 3X/WEEK (___) This
medication was held. Do not restart Spironolactone until your
doctor says to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on Chronic systolic Heart Failure
___ on CKD
Type II NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
From a medical perspective, no contra-indication for cataract
surgery on ___.
Followup Instructions:
___
Radiology Report
EXAMINATION: AP chest radiograph
INDICATION: History: ___ with cough, dyspnea// pna?
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
There is a left lower lobe opacity in ill-defined linear opacities in the
right lower lobe. There is a small right pleural effusion. Mild cardiomegaly
is unchanged. Dextroscoliosis of the thoracic spine is noted.
IMPRESSION:
1. Left lower lobe opacity could represent aspiration or pneumonia.
2. Ill-defined linear opacities overlying the right lower lobe favor
atelectasis versus less likely pneumonia or aspiration.
3. Small right pleural effusion.
Radiology Report
INDICATION: ___ year old man with SOB, chest pain// eval for fluid overload,
pneumonia
TECHNIQUE: PA and lateral
COMPARISON: Portable chest x-ray ___
FINDINGS:
There are bilateral lower lobe opacities, likely atelectasis; however,
pneumonia cannot be completely excluded. There is a stable small right
effusion. The heart is enlarged, similar to previous. The aorta is tortuous.
The bones are diffusely osteopenic. There is scoliosis and degenerative
changes of the spine. Degenerative changes are seen in the shoulder.
IMPRESSION:
Bilateral lower lobe opacities, likely atelectasis however pneumonia cannot be
completely excluded. Mild cardiomegaly. Small stable right effusion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 96.9
heartrate: 68.0
resprate: 20.0
o2sat: 99.0
sbp: 138.0
dbp: 79.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ h/o HFrEF (EF 20% ___, asthma, CAD
s/p PCI to AD & ramus in ___, mild AR and MR, CKD (b/l
Cr~1.7-2.0), hypertension, GERD, and OSA who presented with
chest pain, cough, and difficulty breathing in absence of clear
infection or COPD/asthma exacerbation. Breathing improved on
diuretics. Chest pain in setting of rising troponins (to 0.22),
improved on Nitro SL. Cardiology pursued medical management of
possible angina. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenergan Plain / Aldactone / Digoxin / amlodipine
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with DM II, ESRD on HD, CAD s/p CABG, CHF, HTN, HLD, prior
R CVA in ___, who presented ___ with altered mental status and
ultimately found to have L CVA.
Per her husband, she had developed cough and mild dyspnea on
___ and was seen by her PCP who diagnosed her with PNA by CXR
on ___ and started her on levofloxacin. She seemed to improve
from a respiratory standpoint and was otherwise well until the
morning of ___ when she was noted to be talking incoherently
and was somnolent when seen by someone who was doing her hair.
She was saying random but accurate sentences saying "I am going
away", "I am going home", "when am I getting off".
No noted seizures, fevers, chills, abdominal pain, diarrhea
preceding AMS.
In the ED, neuro felt that the patient had a toxic-metabolic
encephalopathy due to a large dose of Keppra, possibly
potentiated by levofloxacin. Cardiology was consulted due to ST
depressiosn and elevated troponins, but in the setting of missed
HD, they felt ACS treatment was not warranted.
On initial assessment on the floor, she was awake, but unable to
converse, unable to follow commands, and not oriented to
person/place/time. The patient received HD on ___.
On ___, the patient was triggered for unresponsiveness and a CT
head was ordered out of concern for acute CVA, which revealed a
large CVA in the left temparoparietal region. The stroke team
recommended no anticoagulation/tPA due to infarct size and the
risk for hemorrhagic conversion, but recommended supportive care
with permissive hypertension, EEG, and initiating secondary
prevention.
On transfer, vitals were T 97.7, BP 150/53, HR 84, SaO2 97% on
RA.
On arrival to the MICU, the patient is unresponsive.
Review of systems: Unable to obtain
Past Medical History:
- R MCA stroke vs. TIA in ___ without residual deficit per
husband
- ___ disorder
- C. Diff Colitis
- Ishemic colitis x2: two episodes of ischemic colitis, one in
___ and another in ___, both occuring when she
was hypotensive
- pnemobilia
- DM-II (complicated by Diabetic neuropathy)
- ESRD on HD - ___ through R-sided HD catheter.
- chronic infrarenal aortic dissection
- right common femoral artery aneurysm
- CAD: s/p 5V CABG ___ echo ___ cath ___ showed 3V
disease. Cath ___ w successful stenting of the LMCA into LAD
with Endeavor DES.
- Chronic diastolic CHF (last EF 50-55%)
- PVD - s/p angioplasty in LLE and s/p bypass in RLE
- HTN
- Hyperlipidemia
- Sensorineural hearing loss - partial loss in Left ear, with
hearing aid; complete loss in R ear
- COPD: ___ PFT showed reduced FVC with low-normal TLC
- Chronic low back pain
- s/p cataract surgery
- Depression
- Left breast cyst at 2 o'clock, 5 cm from the nipple. Patient
also has history of a nodular asymmetry in the left medial
breast with ___ mammograms showing BiRads 3.
Social History:
___
Family History:
2 parents and 6 siblings all died of DM and heart disease. H/o
prostate, colon/stomach, and ovarian CA in siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM
T 97.7, BP 150/53, HR 84, SaO2 97% on RA.
General- Elderly woman is unresponsive, does not follow
commands.
HEENT- Conjugate gaze toward the right, with ptosis of right
eyelid and R facial droop. Pupils are equal, round, and
reactive to light bilaterally. Minimal gag reflex.
Neck- No JVD
CV- RRR, no m/r/g
Lungs- CTAB anteriorly.
Abdomen- Soft, nontender.
GU- No foley
Ext- Trace edema
Neuro- Unresponsive. Moving all extremities except LLE, has
left-sided hemineglect. Eye exam as above. Patient not able to
follow commands. She appears awake and eyes open spontaneously.
She localizes to pain. Later during the exam she vocalizes
some incomprehensible sounds.
DISCHARGE PHYSICAL EXAM:
Tmax: 36.8 °C (98.3 °F)
Tcurrent: 36.4 °C (97.6 °F)
HR: 87 (73 - 94) bpm
BP: 153/48(74) {120/35(58) - 164/93(103)} mmHg
RR: 16 (14 - 22) insp/min
SpO2: 94%
Neuro: Mental Status- Awake, not oriented to person, place, or
time.
Mumbles "okay" repeatedly. Does not follow any directions.
CN- PERRL 2mm-->1.5 mm, eye movements are normal, no facial
asymmetry, tongue is midline.
Motor- normal tone bilaterally, moves all limbs spontaneously
and
withdraws all limbs from noxious stimulation.
Sensory- Withdraws all limbs from noxious stim, says "ouch",
does
not localize stimulus well.
Neck: No JVD
Chest: RRR no m/r/g, HD catheter in place
Lungs: CTAB anteriorly.
Abdomen: Soft, nontender.
GU: No foley
EXT: Trace edema, Moving all extremities except LLE; did wiggle
her toes noxious stimulus
Pertinent Results:
___ 01:00PM BLOOD WBC-8.1 RBC-3.10* Hgb-10.3* Hct-31.1*
MCV-100* MCH-33.2* MCHC-33.1 RDW-13.1 Plt ___
___ 06:39AM BLOOD WBC-8.3 RBC-3.26* Hgb-10.5* Hct-32.9*
MCV-101* MCH-32.2* MCHC-32.0 RDW-12.6 Plt ___
___ 04:05AM BLOOD WBC-9.3 RBC-3.35* Hgb-11.1* Hct-33.8*
MCV-101* MCH-33.1* MCHC-32.8 RDW-13.4 Plt ___
___ 01:00PM BLOOD Glucose-315* UreaN-61* Creat-6.6* Na-142
K-6.6* Cl-99 HCO3-29 AnGap-21*
___ 06:39AM BLOOD Glucose-172* UreaN-68* Creat-7.7*# Na-143
K-5.1 Cl-99 HCO3-29 AnGap-20
___ 04:05AM BLOOD Glucose-118* UreaN-33* Creat-4.6*# Na-138
K-4.2 Cl-96 HCO3-30 AnGap-16
___ 01:00PM BLOOD ALT-93* AST-71* CK(CPK)-75 AlkPhos-82
TotBili-0.3
___ 03:58AM BLOOD WBC-9.9 RBC-3.56* Hgb-11.6* Hct-35.7*
MCV-100* MCH-32.4* MCHC-32.4 RDW-13.4 Plt ___
___ 03:58AM BLOOD Glucose-198* UreaN-44* Creat-4.9*#
Na-131* K-3.6 Cl-92* HCO3-22 AnGap-21*
___ 04:05AM BLOOD Triglyc-159* HDL-26 CHOL/HD-3.2
LDLcalc-25
C. Diff - NEGATIVE (___)
ECHO (___)
The left atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Overall left ventricular systolic
function is moderately depressed - quantitative (biplane) LVEF =
35% - secondary to hypokinesis of the basal-mid inferior wall
and hypokinesis of the entire anterior wall, apex, and anterior
septum. Right ventricular chamber size is normal. with mild
global free wall hypokinesis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, there are new left ventricular wall
motion abnormalities with worse biventricular global systolic
function. Mitral regurgitation has progressed from mild to
moderate. No evidence of intracardiac shunt.
EEG (___)
FINDINGS:
EEG is recorded from 7 AM on ___ until 7 AM on ___. Left
hemisphere
electrodes are disconnected from 1 ___ until 4 ___, and there is
continuous 60 Hz artifact over the right hemisphere at the same
times. There is continuous O2 artifact after 2 AM, and eye leads
are disconnected throughout most of the study.
CONTINUOUS EEG: The background activity consists predominantly
of polymorphic theta and delta activity. There is no definite
posterior dominant rhythm. There is continuous focal slowing,
more prominent polymorphic delta activity, and mild attenuation
of faster frequencies in the left temporal region. There are no
epileptiform discharges or electrographic seizures.
SLEEP: No normal sleep architecture is present. There are some
segments with decreased muscle activity and overall slowing of
the background, but no sleep transients are seen.
PUSHBUTTON ACTIVATIONS: There are 5 pushbutton activations, at
10:27, 11:29, 11:30, and 2 at 12:00. During these pushbuttons,
only the patient's head is visible on video. Reportedly, the
pushbuttons are for some erratic movements of her legs. There
are no EEG changes during these pushbuttons.
SPIKE DETECTION PROGRAMS: There are frequent automated spike
detections,
predominantly for electrode and movement artifact. There are no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: Seizure detection programs did not
detect any
electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels include automated seizure detection, rhythmic
run detection and display, color spectral density array,
absolute and relative asymmetry indices, asymmetry spectrogram,
amplitude integrated EEG, burst suppression ratio, envelope
trend, and alpha delta ratios. Segments showing abnormal trends
are reviewed, and show diffuse background slowing with more
prominent left temporal slowing.
CARDIAC MONITOR: Shows a generally regular rhythm with no
apparent P waves and a wide QRS complex at an average rate of
60-70 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
continuous focal slowing and attenuation of faster frequencies
in the left
temporal region. These findings are indicative of a focal
structural lesion in the left temporal region, consistent with
the patient's known history of stroke. Background activity is
otherwise slow and disorganized, indicative of moderate diffuse
cerebral dysfunction, which is etiologically nonspecific. No
electrographic seizures or epileptiform discharges are present.
Five pushbutton activations for movements of her legs had no
ictal EEG correlate. The type of leg movements could not be
determined because only her head was visible on video at this
time. Compared to the prior day's recording, there are no
epileptiform discharges, but background activity is otherwise
unchanged.
CT HEAD ___
Again seen is an evolving left MCA distribution infarct,
involving the
temporal and parietal lobes with continued edema, similar to the
prior study. Linear areas of hyperdensitywithin (2a:19) may
represent retained contrast due to slow flow as suggested on
prior studies or possible hemorrhagic conversion. The superior
right frontal lobe hypodense area consistent with an evolving
infarction is stable from the prior study. A linear focus seen
within this region (2a: 18) is new since the prior exam. A
large area of encephalomalacia in the right temporoparietal area
stable. There is no shift of the midline structures and the
basilar cisterns are patent. The ventricles and sulci are
unchanged in size and configuration, with continued effacement
of the occipital horn of the left lateral ventricle. The
visualized paranasal sinuses and the middle ear cavities are
clear. The mastoid air cells are underpneumatized.
IMPRESSION:
1. Similar appearance of evolving left MCA infarction with
similar appearing linear foci of hyperdensity which may
represent retained contrast, however involving blood products
is also possible.
2. Evolving right frontal infarction in the superior right MCA
territory
stable from the prior study. Linear hyperdense focus within
this region which may also represent retained contrast or
evolving blood products.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 100 mg PO HS
3. Atorvastatin 40 mg PO DAILY
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Carvedilol 25 mg PO BID
6. NPH 14 Units Breakfast
7. LeVETiracetam 1000 mg PO BID
8. Losartan Potassium 100 mg PO DAILY
9. NIFEdipine CR 30 mg PO QHS
10. ___ Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral
daily
11. vancomycin *NF* 125 mg ORAL DAILY
12. Nitroglycerin SL 0.4 mg SL PRN cp
13. Probiotic *NF*
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
Oral daily
14. Levofloxacin 500 mg PO Q48H
Please start ___, next dose ___, then end
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. NPH 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. LeVETiracetam 500 mg PO BID
6. LeVETiracetam 500 mg PO POST HD
7. Losartan Potassium 25 mg PO DAILY
8. Vancomycin Oral Liquid ___ mg PO Q6H
9. Calcium Carbonate 1000 mg PO TID
10. Lorazepam 0.5-1 mg IV X1:PRN seizure
11. Phenytoin Infatab 150 mg PO Q8H
12. Calcium Acetate 1334 mg PO TID W/MEALS
13. Probiotic *NF*
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
Oral daily
14. ___ Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral
daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke, Ischemic
Seizures
Secondary:
DM Mellitus, type II, well controlled
CHF, systolic w/ EF ___
Coronary Artery Disease
ESRD on HD
Hypertension
Hyperlipidemia
COPD w/o exacerbation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Altered mental status.
COMPARISON: Non-contrast head CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformatted
images were generated.
FINDINGS:
There is no hemorrhage, edema, mass effect, or vascular territorial
infarction. Right temporoparietal encephalomalacia is unchanged compared to
the prior examination. Prominent ventricles and sulci reflect age-related
atrophy. Periventricular white matter hypodensities likely reflect sequelae
of chronic small vessel ischemic disease. Basal cisterns are patent and there
is preservation of gray-white matter differentiation. No fracture is
identified. Paranasal sinuses show mild mucosal thickening within the left
maxillary sinus. Remaining paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Orbits are unremarkable.
Calcifications are noted in the cavernous carotids.
IMPRESSION: No acute intracranial abnormalities.
Radiology Report
HISTORY: ___ female with altered mental status with recent pneumonia.
COMPARISON: ___.
FINDINGS:
AP and lateral views of the chest. Left sided dual-lumen central venous
catheter seen with distal tip in the right atrium, similar to prior. The
lungs are hyperinflated. Increased interstitial markings are seen throughout
the lungs similar to prior given differences in technique. More confluent
consolidation is seen in the left lung, minimally improved since prior. There
is now blunting of the posterior costophrenic angles suggestive of small
effusions. Cardiomediastinal silhouette is enlarged but stable. No acute
osseous abnormality detected.
IMPRESSION:
Mild interval improvement in the appearance of the left lung consolidation
which persists. As mentioned on prior, followup will be necessary after
treatment. Trace pleural effusions. No other change.
Radiology Report
STUDY: CTA of the head and neck with and without contrast.
CLINICAL INDICATION: ___ woman with right-sided facial droop,
evaluate for acute bleed.
COMPARISON: Prior CTA of the head dated ___ and prior MRI of the
brain dated ___.
TECHNIQUE:
NON-CONTRAST HEAD CT: Axial MDCT images were obtained through the brain, no
contrast was administered, the images were reviewed using soft tissue and bone
window algorithms.
CTA OF THE HEAD AND NECK: Axial MDCT images were obtained from the aortic
arch through the head convexity with intravenous contrast. Axial, coronal,
sagittal, and thick-slab multiplanar reformations were generated.
FINDINGS:
HEAD CT WITHOUT CONTRAST: Since the most recent head CT dated ___,
there is a new large area of low attenuation in the left temporo-occipital and
parietal region, vascular territory of the posterior branches of the left MCA
with no evidence of hemorrhagic transformation. Again a chronic infarction is
identified in the vascular distribution of the right MCA with extensive area
of encephalomalacia.
CTA OF THE HEAD: There is a filling defect, suggesting occlusion of the left
M2 inferior division branch (3:251), again there are calcified plaques in the
petrous and cavernous segments of both intracranial internal carotid arteries
and intracranial vertebral arteries. The anterior and right middle cerebral
arteries are patent as well as the posterior circulation. No aneurysms larger
than 3 mm in size are seen.
CTA OF THE NECK: Again, common origin of the left common carotid and
brachiocephalic artery is redemonstrated. There are atherosclerotic
calcifications in the aortic arch and calcified atherosclerotic plaques are
redemonstrated in bilateral common carotid arteries with no significant change
since the most recent study, punctate calcifications are visualized in the
petrous and cavernous segments bilaterally involving the internal carotid
arteries.
The thyroid gland is notable for heterogeneous hypodense nodules, previously
demonstrated, there is persistent and more significant pleural effusion and
right upper lobe and consolidation. Multilevel degenerative changes are
visualized throughout the cervical spine, more significant at C5/C6 level.
The patient is status post CABG.
IMPRESSION: Acute left temporo-occipitoparietal lobe infarction, suggesting
occlusion of the M2 segment involving the inferior division branch as
described in detail above (3:251). Unchanged right temporal extensive
encephalomalacia in the vascular territory of the right middle cerebral
artery.
These findings were discovered and communicated via phone call by ___
to Dr. ___ on ___ at 20:31 p.m.
Radiology Report
HISTORY: Left-sided CVA. Question hemorrhagic conversion.
TECHNIQUE: Noncontrast head CT.
COMPARISON: ___.
FINDINGS:
There is increased swelling of the left MCA distribution infarction. Within
this are linear areas of hyperdensity. Although these may reflect hemorrhage
into the infarct, there is persistent high density within the left MCA
branches. Thus, this high density may be rather pooling and slow clearance of
contrast from the recent CTA, rather than hemorrhage. The encephalomalacic
area of the right temporal parietal lobe is stable. There is very slightly
increasing shift of the midline by approximately 2 mm. The basal cisterns are
widely patent. The ventricles and sulci are normal in size and morphology for
the patient's age. The mastoid air cells are underdeveloped. Paranasal
sinuses are clear.
IMPRESSION:
Evolution of left MCA infarction. Linear areas of hyperdensity within the left
temporal occipital parietal lobe infarction more likely represents persistent
contrast within the vessels rather than hemorrhage, given their shape.
Radiology Report
HISTORY: Large left-sided CVA; prior R MCA CVA. Please evaluate for stroke
evolution and signs of hemorrhage.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DLP: 1025.7 mg/cm.
COMPARISON: CT head without contrast from ___.
FINDINGS:
Again seen is an evolving left MCA distribution infarct involving
predominantly the temporal and parietal lobes, with continued edema, similar
in extent to the prior study. The linear areas of hyperdensity seen within
the infarct on the prior study have resolved, consistent with pooling of
contrast from a prior CTA. There is no evidence of hemorrhagic conversion.
The area of encephalomalacia in the right temporal and parietal lobes are
stable. Deep and periventricular white matter hypodensities are again seen,
likely sequela of chronic small vessel ischemic disease. There is no
significant shift of the midline structures. Basilar cisterns are patent. The
ventricles and sulci are unchanged in size and configuration, with effacement
of the atrium and occipital horn of the left lateral ventricle. The mastoids
are underpneumatized. The imaged paranasal sinuses, mastoid antra and middle
ear cavities are clear. There is calcification of the carotid siphons.
IMPRESSION:
Similar appearance of the evolving left MCA infarction with no evidence of
hemorrhagic conversion. Continued effacement of the left temporoparietal
sulci without increasing mass effect.
NOTES ON ATTENDING REVIEW:
1. Linear foci of hyperdensity along the evolving left MCA infarction have
decreased in density, but not completely resolved; the largest residual focus
is best seen on image 2:15. This is compatible with either slow resorption of
retained intravascular contrast or evolving blood products.
2. There is also an evolving right frontal infarction in the superior right
MCA territory, with loss of gray/white matter differentiation but no
significant mass effect, new since ___, without hemorrhagic
transformation.
Radiology Report
HISTORY: For Dobbhoff placement.
FINDINGS: In comparison with study of ___, there has been placement of the
Dobbhoff tube with the opaque portion straddling the gastroesophageal
junction. Diffuse bilateral pulmonary opacifications persist.
Radiology Report
HISTORY: History of large left-sided CVA. Evaluate for signs of evolution
or hemorrhagic conversion.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material.
DLP: 1538 mGy-cm.
COMPARISON: Multiple prior studies most recently CT head without contrast
from ___.
FINDINGS:
Again seen is an evolving left MCA distribution infarct, involving the
temporal and parietal lobes with continued edema, similar to the prior study.
Linear areas of hyperdensitywithin (2a:19) may represent retained contrast due
to slow flow as suggested on prior studies or possible hemorrhagic conversion.
The superior right frontal lobe hypodense area consistent with an evolving
infarction is stable from the prior study. A linear focus seen within this
region (2a: 18) is new since the prior exam. A large area of
encephalomalacia in the right temporoparietal area stable. There is no shift
of the midline structures and the basilar cisterns are patent. The ventricles
and sulci are unchanged in size and configuration, with continued effacement
of the occipital horn of the left lateral ventricle. The visualized paranasal
sinuses and the middle ear cavities are clear. The mastoid air cells are
underpneumatized.
IMPRESSION:
1. Similar appearance of evolving left MCA infarction with similar appearing
linear foci of hyperdensity which may represent retained contrast, however
involving blood products is also possible.
2. Evolving right frontal infarction in the superior right MCA territory
stable from the prior study. Linear hyperdense focus within this region which
may also represent retained contrast or evolving blood products.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALTERED MENTAL STATUS
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.2
heartrate: 86.0
resprate: 20.0
o2sat: 100.0
sbp: 156.0
dbp: 56.0
level of pain: 13
level of acuity: 1.0 | The patient is a ___ year old female with a past medical history
significant for DMII, ESRD on HD, CAD s/p CABG, CHF, HTN, HLD
and seizures who presented with altered mental status found to
have new left parietal stroke.
#) ACUTE CEREBROVADSCULAR ACCIDENT: Left MCA stroke with
previous R MCA stroke recrudescence.
In the ED, the patient was able to speak in sentences, but the
sentences did not make sense. She was also having difficulty
following commands. A neurology consult was obtained and they
felt as though this was likely a toxic metabolic encephalopathy
due to a large dose of Keppra, possibly exacerbated by the
Levofloxacin she was receving for her PNA. An EEG was also
obtained in the ED, which did not show non-convulsive seizures
or epileptiform discharges.
On initial assessment on the floor, she was awake, but unable to
converse, unable to follow commands, and not oriented to
person/place/time. The patient received HD on ___.
On ___, the patient was triggered for unresponsiveness and a CT
head was ordered out of concern for acute CVA, which revealed a
large CVA in the left temparoparietal region. The stroke team
recommended no anticoagulation/tPA due to infarct size and the
risk for hemorrhagic conversion, but recommended supportive care
with permissive hypertension, EEG, and initiating secondary
prevention. She was then transferred to the MICU for closer
monitoring. She was started on PR aspirin and her home BP meds
were discontinued. Repeat serial CT scans were obtained. There
was initially some concer for hemorrhagic conversion, and ASA
was briefly held, although images were thought more consistent
with late contrast extravasation and ASA was restarted. Due to
persistently poor mental status, a dobhoff tube was placed for
enteral feedings.
Her course was complicated by subclinical seizure activity on
EEG. She was started on phenytoin in addition to her home
levitiracetam dosing, and she received intermittent lorazepam IV
for possible seizure activity with good effect. By discharge,
she was having no more seizure activity, and her medications
were switched to PO.
#) NSTEMI: Likely represent missed NSTEMI. Drawn in ED given ST
depression seen on ECG and noted to be markedly elevated to ~6.
Serial measurements were generally flat with low MB fraction.
Cardiology was consulted due to ST depressions seen on EKG and
elevated troponins. In the settings of missed HD, they did not
feel that ACS treatment was warrented. ST segment depressions
persisted throughout her hospitalization. Following the
identification of her stroke, an echocardiogram was obtained
which showed new ___ wall motion abnormalities and
decreased LVEF. Patient was not clinically in heart failure. Her
ASA, carvedilol and losartan was restarted, at lower doses given
MAP goals.
#) COMMUNITY-ACQUIRED PNEUMONIA: Respiratory status was stable
on admission and no further clinical evidence of PNA although
infiltrate persisted on CXR. She was switched to
ceftriaxone/azithromycin from levofloxacin and completed a 7 day
course of abx.
#) RECURRENT C. DIFF COLITIS: Patient was being treated with PO
vancomycin at home for recurrent C. diff colitis but was
switched to metronidazole and admission. This was switched back
to po vancomycin after enteral access with dobhoff was
established on ___. She had no clinically signficant diarrhea
and repeat CDiff PCR was negative. She should continue with PO
vancomycin until ___ to complete two weeks of C. diff
treatment following antibiotics.
CHRONIC PROBLEMS
================
#) CHRONIC KIDNEY DISEASE, STAGE V: Continue HD. Last received
dialysis ___. Should continue to receive HD MWF.
#) CONGESTIVE HEART FAILURE, COMPENSATED: No evidence of
decompensation currently. Held beta blocker and ___ after stroke
for permissive hypertension, which were slowly restarted.
Restarted Carvedilol and Losaratan. Echo showed worsened wall
motion abnormalities and LVEF as above, although clinically
patient was stable.
#) DIABETES MELLITUS: Continued HISS. Gabapentin was held given
somnolence. A1c was measured at 6.9%
#) DYSLIPIDEMIA: Repeat lipids to tailor secondary stroke
prevention therapy.
#) HYPERTENSION: Goal systolic 110 to 140 to help with perfusion
since she had a stroke. Restarted Carvedilol and Losartan.
===========================
CONTACT / CODE STATUS
===========================
# CODE: Full code (confirmed)
# CONTACT: ___ (husband) home ___, cell
___
===========================
### TRANSITIONAL ISSUES ###
===========================
- please check phenytoin trough in two days (___) with
target = ___.
- please check electrolytes on ___ and ___. replete K
to 4, phos to 3, and Mg to 2
- please maintain systolic blood pressure above 110 to help with
perfusion since she had a stroke, if persistently below 110,
please hold antihypertensives until pressures can tolerate these
medications
- please continue HD MWF
- please avoid haloperidol since this decreases the seizure
threshould |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Tape ___
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ PROCEDURE: Exploratory laparotomy, lysis of adhesions
(Dr. ___
History of Present Illness:
Mr. ___ is a ___ male with PMH most notable for ESRD
due to polycystic kidney disease s/p deceased donor renal
transplant on ___ ___. His early post-transplant
course was complicated by acute cellular rejection within 2
months and a humoral rejection response about 8 months later, as
well as BK nephropathy. He has been doing quite well in this
regard since then, however, with stable renal function and a
stable regimen of Prograf, prednisone and azathioprine. His
PMH/PSH is also notable for b/l inguinal hernia repairs in ___,
with the left side presenting as an incarcerated SBO, not
requiring any bowel resection.
He presented to the ED ___ complaining of sudden-onset
diffuse crampy abdominal pain since the previous evening, which
had been waxing and waning,with +nausea and emesis x 1
(non-bloody/non-bilious). He reported no longer passing any
flatus since this pain began. His last bowel movement was the
morning of ___, reportedly much smaller than his usual, with no
blood/mucus. He reports no fevers/chills, no CP/SOB, no
dysphagia. An NGT was placed in ED with return of ~400cc of
light green fluid, and a small degree of relief reported by the
patient thereafter.
Past Medical History:
Past Medical History: ESRD from polycystic kidney disease s/p
renal transplant in ___, BK nephropathy, HTN, gout, BPH,
osteoporosis
Past Surgical History: lap-assisted PD catheter placement
___ - Dr. ___, removal and replacement of infected PD
cathether ___ - Dr. ___, L inguinal hernia repair
___ - Dr. ___, R inguinal hernia repair ___ -
Dr. ___, deceased donor renal transplant ___ - Dr.
___, removal of PD catheter ___ - Dr. ___
Social History:
___
Family History:
No family history of DVT or PE. No family history of kidney
disease. Father died at ___ related to progressive dementia.
Mother died at ___, had colon cancer in ___. Two sisters and a
brother who are all in good health.
Physical Exam:
Exam on admission:
Vitals: 98.8 56 136/89 18 100%RA
GEN: oriented x3, calm,cooperative
HEENT: No scleral icterus
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, mildly distended, mildly tender to deep palpation in
epigastrium>LUQ>LLQ, no rebound/rigidity/guarding, no palpable
masses, small umbilical hernia with ~2-cm palpable defect and
protrusion of easily reducible fat contents, well-healed old
surgical scars
Ext: No ___ edema/cyanosis/clubbing
Exam on discharge:
VS: 98.3 50 145/98 18 100RA
Gen: AAOx3, pleasant and cooperative
CV: Regular
Pulm: Clear
Abd: Soft, nondistended, with appropriate local incisional
tenderness. Incision clean and dry with minimal staple
erythema, stable over the past two days. Well healed prior
surgical scars.
Ext: Warm, no edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 3 mg PO Q12H
2. PredniSONE 2.5 mg PO DAILY
3. Azathioprine 50 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Enalapril Maleate 20 mg PO DAILY
6. Furosemide 20 mg PO DAILY:PRN edema
7. Tamsulosin 0.4 mg PO HS
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Frequency is
Unknown
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Azathioprine 50 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. PredniSONE 2.5 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Prograf (tacrolimus) 2 mg oral Q12
7. Tamsulosin 0.4 mg PO HS
8. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg per day
9. Docusate Sodium 100 mg PO BID
decrease or stop if frequent stool or diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
10. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*4
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
12. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Tablet Refills:*0
13. Furosemide 20 mg PO DAILY:PRN edema
as directed by your nephrologist
Discharge Disposition:
Home
Discharge Diagnosis:
Small-bowel obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History of small bowel obstruction with multiple hernias
presenting with sudden onset abdominal pain and obstipation, rule out
obstruction or free air.
COMPARISON: CT torso dated ___.
FINDINGS: Frontal upright and supine radiographs of the abdomen were
obtained. An NG tube is present with the tip in the left upper quadrant.
Dilatd loops of small bowel are seen in the left upper quadrant. There are
other multiple scattered air-fluid levels seen on the upright exam in this
region as well as in the right lower quadrant. Calcifications bilaterally,
which are coarse, curvilinear corresponding to calcifications within renal
cyst seen on prior CT. Leftward curvature of the lumbar spine is noted. No
free intraperitoneal air is identified. A surgical clip projects over the
left femoral head.
IMPRESSION:
1. Slighty dilated loops of small bowel with air fluid levels in the left
upper quadrant raising possibility of obstruction.
CT scan had already been ordered at time of interpretation to further assess.
2. Extensive calcifications bilaterally corresponding to calcifications
within renal cysts as seen on prior CT.
Radiology Report
INDICATION: Possible small-bowel obstruction seen on the KUB. Has a history
of a renal transplant in the left lower quadrant.
COMPARISONS: CT of the torso from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis after the administration of oral contrast only. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 701.96 mGy-cm.
FINDINGS:
LUNG BASES: There is dependent bibasilar atelectasis, worse on the left than
the right. There is no discrete nodule, consolidations, or pleural effusion.
The base of the heart is normal in size. Trace pericardial fluid is within
the normal physiologic range.
ABDOMEN: The liver is normal in size with multiple hypodensities, consistent
with cysts. Several of these cysts have calcifications. One of the cysts
right lobe of the liver (2, 12) has become more calcified since the prior
exam. The remainder of the cysts are grossly stable. There is no intra- or
extra-hepatic biliary duct dilation. The gallbladder, spleen, pancreas, and
adrenal glands are normal. The native kidneys are enlarged with innumerable
small and large cysts, many of which have peripheral calcifications. The
largest on the right measures 13.2 cm and is slightly hyperdense, and likely a
hemorrhagic or proteinaceous cyst. These are poorly characterized without
intravenous contrast.
An NG tube is present with the tip in the stomach. The jejunum, and probably
proximal loops of the ileum, and mildly dilated measuring up to 3.3 cm. There
is oral contrast throughout the proximal loops, which then becomes diluted.
In the left mid abdomen, there is evidence of fecalized material, and a
gradual change in caliber in the bowel dilation (2, 59 and 601b, 20) with
completel distal decompression. This is consistent with a small bowel
obstruction. The loops proximal to transition do not demonstrate wall
thickening or pneumatosis. The bowel wall enhances homogeneously. There is a
small amount of fluid in the mesentery, as well as in the left abdomen. The
distal loops are completely collapsed. The colon is also mostly collapsed.
The abdominal vasculature is normal in caliber with moderate atherosclerotic
calcifications. There is no mesenteric, retroperitoneal, or periportal
lymphadenopathy.
PELVIS: There is diverticulosis without evidence of diverticulitis. The
large bowel is mostly collapsed. The appendix is not definitely visualized,
though there are no secondary signs of appendicitis in the right lower
quadrant. There is a small amount of fluid and stranding along the left
paracolic gutter. Additionally, there is a small amount of free fluid in the
pelvis. The bladder and prostate are unremarkable. There is no pelvic or
inguinal lymphadenopathy. In the left lower quadrant, there is a transplanted
kidney, which is similar in appearance to the prior exam. There is no
hydronephrosis or evidence of a renal mass. There is no perinephric fluid
collection.
Again, there is a left inguinal hernia, which contains fluid. Overall, the
amount of fluid in the hernia appears to have decreased since the prior exam
in ___.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. No fracture is identified. Bilateral L5 spondylolysis is seen.
Anterolisthesis of L5 on S1 has progressed since the prior exam. Other
moderate multilevel degenerative changes in the spine are unchanged.
IMPRESSION:
1. Small bowel obstruction with a gradual transition point in the left mid
abdomen. There is complete collapse of the distal small bowel loops. There
is no bowel wall thickening, pneumatosis or free air. There is a small amount
of nonspecific fluid around the dilated loops of bowel, in the left paracolic
gutter, and layering in the pelvis.
2. Polycystic kidney and liver disease, grossly similar to the prior exam.
These cysts are incompletely characterized without intravenous contrast.
3. Normal appearance of the transplanted kidney without hydronephrosis.
4. Fluid-containing left inguinal hernia.
5. Diverticulosis without diverticulitis.
6. Interval worsening of the anterolisthesis of L5 on S1.
Changes to the wet read were discussed with Dr. ___ at 8:30 ___ on ___
via telephone by Dr. ___.
Radiology Report
INDICATION: Abdominal pain. Evaluate for cholecystitis.
COMPARISONS: CT of the abdomen from ___, obtained immediately
prior to this ultrasound.
TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the
upper quadrants.
FINDINGS: The liver is normal in shape and contour. There are innumerable
cysts throughout the liver, compatible with polycystic liver disease. These
are better characterized on the CT. The largest is in the right lobe and
measures 6.2 cm. The hepatic parenchyma between the cysts demonstrates normal
echogenicity. The main portal vein is patent with normal hepatopetal flow.
There is no intra- or extra-hepatic biliary duct dilation. The intra-hepatic
common bile duct measures 6 mm. In the proximal extra-hepatic region, there
is mild prominence of the duct, up to 8 mm, though it tapers smoothly. No
filling defect is identified.
The gallbladder is not distended. There are two echogenic foci, which are not
definitely mobile or shadowing. These likely represent two polyps. There are
no definite stones or sludge. There is no gallbladder wall thickening or
pericholecystic fluid to suggest cholecystitis.
The pancreas is not well evaluated due to overlying bowel gas. The spleen is
somewhat distorted by the adjacent polycystic kidneys, so appears elongated,
though is likely normal in size. Limited views of the kidneys demonstrate
multiple cysts, again better characterized on the CT. The largest is
exophytic off the right upper pole and measures 11.1 x 10.6 x 9.9 cm. There
are diffuse low-level echoes throughout this cyst, suggesting the cyst is
hemorrhagic or proteinaceous. There is no nodularity or internal flow.
IMPRESSION:
1. Two sub-5-mm gallbladder polyps. No definite stones. No cholecystitis.
2. Polycystic liver and kidney disease, better characterized on the
concurrent CT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.8
heartrate: 56.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 89.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was evaluated by the transplant surgery team in the
ED after initially presenting with abdominal pain, nausea, and
emesis. In the setting of several prior abdominal operations,
his history, exam, and CT were concerning for small bowel
obstruction with transition point in the left-mid abdomen. He
was admitted to the transplant service for NG decompression, IV
hydration, and serial abdominal exams.
On ___, Mr. ___ developed acute, severe abdominal pain and
was taken to the operating room for exploratory laparotomy and
lysis of adhesions. No definitive transition point was
identified.
Post-operatively, Mr. ___ recovered well. He was ambulatory
on ___, and the NG tube was removed on ___. Bowel function
returned on ___, and his diet was subsequently advanced, which
Mr. ___ tolerated without difficulty. As he was moderately
hypertensive, home enalapril and amlodipine were restarted ___
when he was able to take oral medications. When hypertension to
SBP 160s persisted, metoprolol 12.5 BID was started on ___ -
this was a former home medication - with good effect.
Of note, his tacrolimus dose was decreased from his home regimen
of ___ to ___ after a trough of 14.5 on ___. He will continue
on this lower dose until his next lab draw on ___ and subsequent
follow up with Dr. ___.
On ___, Mr. ___ was ambulatory, tolerating a regular diet,
and with improved blood pressure control on oral medication (as
above). His incision was healing well and he was otherwise
without complaint. He was deemed stable for discharge to home
with follow up both in the transplant surgery clinic
post-operatively and with his primary care provider for blood
pressure management. He will also follow up with Dr. ___ as
scheduled. He was advised to call the clinic or return to the
ED with any recurrent obstructive symptoms, fever, or sign of
wound infection. Mr. ___ understood these instructions and
agreed with the plan. He was discharged to home on ___ in
good condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
mechanical fall with head strike
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ with history of hepatitis C, CKD, anemia,
on anticoagulation for mechanical AVR/MVR who was admitted after
mechanical fall with head strike on ___ and finding of small
left insular SAH with small IVH component. At that time INR
was 3.3. She was admitted to Neurosurgery and coumadin was held
without being actively reversed (approved by cardiology
consult). Serial NCHCTs were done which were stable until ___
when there was evidence of a small intraparenchymal hemorrhagic
contusion along with the SAH. This was felt to be a normal
sequelae of her head strike.
She was transferred to the medicine service on ___. Her INR
that day was 1.8 and she was started on a heparin gtt with
2900unit bolus as a bridge to coumadin given her mechanical
valves. Both the heparin with bolus was approved by the
neurosurgical team. The night of ___, she had one recorded
elevated PTT to 140s, but subsequent PTTs were in the goal range
of 60-80. That day she was also transfused 1 unit PRBC for
anemia.
The following day ___, her heparin gtt was transitioned to
lovenox 30mg SQ given the plan to discharge her home. Prior to
discharge, she was noted to be lethargic. Around 130pm, she was
even more lethargic and with slurred speech. NCHCT was done at
3pm which showed increasing left temporoparietal hemorrhage,
SAH, and mass effect on the left lateral ventricle.
Stroke neurology saw the patient urgently and found her
hypertensive to 190s/100s, lethargic yet responsive with a right
facial droop, left gaze preference, right sided weakness (right
arm ___, and right leg ___, bilateral upgoing toes. She was
urgently treated with Hydralazine and Labetalol IV doses while
urgently transfering to the NICU under the Neurology service.
BP was controlled (SBP<150) with a nicardipine gtt. No active
reversal was needed as INR was 1.1 and PTT was 34. Serial NCHCTs
were done to reevaluate her IPH and SAH. All anticoagulants were
stopped. Over several days, her exam improved, she became more
attentive, with no gaze preference, and improved strength on the
right.
On ___, she was transferred to the floor. However she
desaturated upon lying flat to the ___ and was placed on a
non-rebreather. Pulmonology performed an ultrasound which showed
atelectasis in the left lung, extensive, as seen on chest x ray
in the morning (likely due to mucus plugging). She was
transferred to the unit. She was given incentive spirometry and
did well, by the end of the day she was saturating well on 3L
nasal cannula. By ___, her chest x ray was improved and she
saturated well on room air. She was then transferred back to the
floor.
Past Medical History:
Depression
Anemia
Alcohol abuse
Atrophic vaginitis
AVR (19mm Regent) and MVR (27mm St ___ on ___ on warfarin
Hepatitis C
Herpes simplex
Hypertension
Migraine headaches
S/p hysterectomy
Tobacco abuse
History of postive RPR
History of microhemorrhages presenting as CVA ___, managed at
___
Social History:
___
Family History:
Mom had breast cancer in her ___. No h/o abdominal/GI diseases.
Family h/o DM (brother, uncle, grandmother).
Physical Exam:
Upon admission:
O: T:98.2 BP: 161/88 HR:77 R 18 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3mm EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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
*****
Pertinent Results:
ADMISSION LABS:
___ 04:30PM BLOOD WBC-4.2 RBC-3.32* Hgb-9.3* Hct-30.1*
MCV-91 MCH-28.0 MCHC-31.0 RDW-15.4 Plt ___
___ 04:30PM BLOOD Neuts-57.2 ___ Monos-7.0 Eos-1.6
Baso-1.3
___ 10:00AM BLOOD ___
___ 04:45PM BLOOD Glucose-107* UreaN-52* Creat-2.9* Na-131*
K-6.4* Cl-103 HCO3-19* AnGap-15
___ 11:20PM BLOOD ALT-50* AST-62* LD(LDH)-253* CK(CPK)-44
AlkPhos-54 TotBili-0.2
___ 11:20PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:15PM BLOOD Calcium-8.6 Phos-4.4 Mg-2.4
___ 04:40AM BLOOD Hapto-<5*
___ 02:15PM BLOOD TSH-6.3*
___ 02:15PM BLOOD T4-6.1
___ 02:29PM BLOOD Type-ART pO2-122* pCO2-32* pH-7.43
calTCO2-22 Base XS--1
___ 07:09PM BLOOD K-5.9*
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-6.1 RBC-2.40* Hgb-7.1* Hct-22.5*
MCV-94 MCH-29.6 MCHC-31.5 RDW-17.4* Plt ___
___ 06:05AM BLOOD ___ PTT-82.1* ___
___ 06:05AM BLOOD Glucose-108* UreaN-43* Creat-1.5* Na-137
K-4.9 Cl-113* HCO3-19* AnGap-10
___ 06:05AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.2
REPORTS:
Non-Contrast Head CT (___) ___:
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the left insular
region.
2. Small amount of intraventricular hemorrhage in the right
lateral
ventricle. No hydrocephalus.
3. No mass effect. Stable ventriculomegaly.
CT C-spine ___:
IMPRESSION: No acute fracture or malalignment of the cervical
spine.
Repeat NCHCT ___: IMPRESSION: Stable left insular region
subarachnoid hemorrhage as well as a small amount of
intraventricular hemorrhage in the right lateral ventricle.
TTE ___: Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. A mechanical aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. [The
amount of regurgitation present is normal for this prosthetic
aortic valve.] A mechanical mitral valve prosthesis is present.
The mitral prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The degree of
mitral regurgitation seen is normal for this prosthesis. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___ the
estimated pulmonary artery pressure is lower. There is slightly
more pulmonic regurgitation. Other findings are similar.
___ ___: IMPRESSION: Interval development of likely focus
of parenchymal hemorrhage, subjacent to the sites of
subarachnoid hemorrhage along the left sylvian fissure,
compatible with hemorrhagic contusions. Associated mild
peripheral edema is seen about these foci of hemorrhage but
there is no evidence of mass effect.
Left Hip US ___: IMPRESSION:
Soft tissue swelling overlying the left hip, with no significant
hematoma
identified.
NCHCT ___: IMPRESSION: No significant change since the
previous exam in subarachnoid hemorrhage in the left sylvian
fissure and two adjacent foci of intraparenchymal hemorrhage.
NCHCT ___: IMPRESSION: Significant increase in size of a
left temporoparietal intraparenchymal hemorrhage with increase
in subarachnoid hemorrhage involving the left frontal sulci
compared to the recent prior exam. There is now increasing mass
effect on the left lateral ventricle which is compressed.
EKG ___: Sinus rhythm. Possible left atrial abnormality.
Possible septal infarction of indeterminate age. Prominent
precordial voltage. Non-specific ST-T wave abnormalities may
represent strain. Cannot rule out ischemia. Suggest clinical
correlation. Compared to the previous tracing of ___ ST-T
wave abnormalities are more marked, including J point ST segment
elevation in leads VI-V2. Suggest clinical correlation and
repeat tracing.
___ ___: IMPRESSION: No significant change in left
frontotemporoparietal intraparenchymal hemorrhage, centered in
the external capsule, with subarachnoid blood layering within
the sylvian fissure and adjacent frontal sulci with unchanged
degree of mass effect, effacing the left lateral ventricle.
Additional punctate focus of hemorrhage in the left anterior
frontal cortex measuring 4 mm is unchanged. No new focus of
hemorrhage or infarct.
NCHCT ___: IMPRESSION:
In comparison to ___ exam, there is no interval change in
known left
intraparenchymal hemorrhage, as described above. There is
surrounding
vasogenic edema and mass effect on the left lateral ventricle
without
significant mass effect. Subarachnoid hemorrhage layering in
the sylvian
fissure and the left sylvian fissure is unchanged. No new focus
of
intracranial hemorrhage.
CXR ___: IMPRESSION: AP chest compared to more ___:
Severe opacification in the left hemithorax is new. The
abnormality obscures much of the left lower lung. I cannot tell
whether it is pulmonary alone or combination of pulmonary and
pleural abnormality. This could be a large pneumonia or a left
lower lobe collapse as well as substantial left pleural
effusion, most likely hemothorax in this patient. I discussed
these findings by telephone with Dr. ___ clinical
profile suggests acute lobar collapse. Imaging confirmation can
be provided by chest CT scanning if appropriate.
Mild pulmonary vascular congestion suggests elevated left atrial
pressure. Patient has had median sternotomy and two cardiac
valve replacements. There is no pulmonary edema.
CXR ___: Cardiomediastinal silhouette including the two
replaced valves is stable. The assessment of the left lung
demonstrates opacification of the mid and lower lung, unchanged
since the prior study and concerning for interval development of
infectious process given the absence of the findings on ___. Aspiration or non-aspiration pneumonia are both a
possibility. Combination of pleural effusion and lobe collapse
should be considered, but the normal pattern of the airways
would make the collapse less likely.
CXR ___: IMPRESSION: AP chest compared to ___:
Some volume loss has developed in the very large consolidation
in the left lower lobe, probably due to aspiration pneumonia and
some airway obstruction due to retained secretions. Right lung
clear. Heart size top normal. The patient has had aortic and
mitral valve replacements. No pneumothorax. There is some
pleural effusion on the left, but not substantial.
CT ABD/PELVIS ___: IMPRESSION:
1. Limited assessment due to lack of IV contrast. No definite
mass is
identified within the abdomen or pelvis.
2. Small amount of free fluid within the abdomen and pelvis.
3. 5mm non-obstructing stones in the lower pole of the left
kidney.
CT HEAD ___: IMPRESSION:
Mild interval decrease in size of large left intraparenchymal
hemorrhage in comparison to the most recent prior noncontrast
head CT of ___ with unchanged extent of subarachnoid
hemorrhage in the left sylvian fissure. Similar minimal
left-to-right midline shift.
CT CHEST ___: IMPRESSION: The opacity in the left lung with
ground-glass and consolidative component likely reflects
pneumonia or aspiration. No other lung parenchymal
abnormalities. No evidence of chronic airways disease or
pleural effusion. Status post CABG and bivalvular replacement.
NCHCT ___: IMPRESSION:
Interval stability in size and morphology of the left
intraparenchymal
hematoma involving the left frontal and left temporal parietal
regions,
compared to ___. Slight increase in surrounding vasogenic
edema but
unchanged mild rightward midline shift and partial effacement of
the left
lateral ventricle. No evidence of new intracranial hemorrhage.
EKG ___: Sinus rhythm. Left atrial abnormality. Delayed R
wave progression in the precordial leads. Cannot exclude prior
anteroseptal myocardial infarction. Prominent voltage and
prominent T waves in the precordial leads. Cannot exclude
myocardial ischemia versus metabolic abnormalities, particularly
hyperkalemia. Compared to the previous tracing of ___
prominent T waves are new. Consider evaluation for hyperkalemia.
CXR ___:
FINDINGS: As compared to the previous radiograph, the
pre-existing left lower lobe pneumonia has almost completely
cleared. Only a small retrocardiac opacity still persists. The
pre-existing elevation of the hemidiaphragm on the left is
improved as compared to the previous image. No pleural
effusion. Unchanged appearance of the right lung and of the
cardiac silhouette.
___ ___: IMPRESSION: Large left intraparenchymal
hemorrhage is unchanged in appearance from CT on ___.
No no evidence of hemorrhage or infarction.
___ ___:
IMPRESSION: Stable appearance of large left intraparenchymal
hemorrhage and associated mass effect.
Portable Abdominal XRay ___: FINDINGS: No free
intra-abdominal air. Several foreign bodies, obviously
clothing, project over the mid abdomen. Moderately distended
stomach. Stool in the rectal ampulla as well as in the
descending colon. Gas filling of the remaining intestinal
component, without evidence of distention or air-fluid levels.
No evidence of wall thickening.
___ ___: Large left intraparenchymal
hemorrhage with associated mass effect is largely unchanged from
the prior study.
CXR ___: IMPRESSION: Resolution of left lower lobe pneumonia
with no evidence of a new infectious process.
___ ___: IMPRESSION: Stable appearance of the evolving
hematoma compared with ___. No significant new
abnormalities are seen.
Microbiology:
UCx from ___ -
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROBACTER AEROGENES. >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 AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. BuPROPion 150 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. LOPERamide 2 mg PO QID:PRN diarrhea
5. Metoprolol Tartrate 100 mg PO BID
6. Mirtazapine 45 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. TraZODone 200 mg PO HS
9. Warfarin 7.5 mg PO DAILY16
10. Multivitamins 1 TAB PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. BuPROPion 150 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Mirtazapine 45 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. TraZODone 100 mg PO HS:PRN insomnia
10. Warfarin 7.5 mg PO DAILY16
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
14. Nimodipine 60 mg PO Q4H
15. Heparin IV
No Initial Bolus
Initial Infusion Rate: 575 units/hr
Goal PTT 50-70. STOP heparin once INR is between 2.5-3.5.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
traumatic ___
intraventricular hemorrhage
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
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Hemorrhagic contusion, evaluation for malignant disease.
COMPARISON: No comparison available at the time of dictation.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
FINDINGS: No incidental thyroid findings. No supraclavicular,
infraclavicular or axillary lymphadenopathy. All visible lymph nodes are
normal in size. Status post CABG with massive aortic wall calcifications,
borderline diameter of the pulmonary artery and replacement of the aortic
valve as well as CABG. The mitral valve is also replaced. No pericardial
effusion. Unremarkable posterior mediastinum. No relevant abnormalities in
the upper abdomen.
The vertebral body show moderate degenerative changes. Status post
sternotomy. No evidence of rib lesions.
Mild respiratory motion artifacts. Mild centrilobular pulmonary emphysema.
Predominating in the left lower lobe and at the posterior aspect of the
lingula is a parenchymal opacity with mixed ground-glass and consolidation
components. The opacity shows multiple air bronchograms. Similar opacities
are found in the right upper lobe. No other parenchymal abnormalities are
seen. The airways are patent. No pulmonary nodules. No evidence of
pulmonary malignancy. Minimal dorsal atelectasis, but no evidence of pleural
effusions. No pathologic pleural thickening.
IMPRESSION: The opacity in the left lung with ground-glass and consolidative
component likely reflects pneumonia or aspiration. No other lung parenchymal
abnormalities. No evidence of chronic airways disease or pleural effusion.
Status post CABG and bivalvular replacement.
At the time of dictation and observation, 2:33 p.m., on the ___, the referring physician, ___, was contacted by telephone, without
success. Therefore, the findings were communicated by E-mail at the same time
point.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with hemorrhagic stroke // Assess for interval
change in bleed size
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891.93 mGy-cm
CTDI: 55.20 mGy
COMPARISON: CT head without contrast ___.
FINDINGS:
Again seen is a large left intraparenchymal hematoma involving the left
frontal and left temporoparietal regions. The morphology and extension of
hemorrhage is not significantly changed compared to prior study of ___, however there is slightly increased surrounding hypodensity. The degree
of vasogenic edema appears slightly more extensive, with unchanged partially
effaced of the left lateral ventricle. Trace left sylvian fissure subarachnoid
hemorrhage is stable. There is no evidence of new intracranial hemorrhage.
Mild 1-2 mm rightward midline shift is stable.
Otherwise, examination is unchanged. The sulci and ventricles are unchanged in
size and configuration. There is no evidence of uncal or tonsillar herniation.
The basal cisterns are adequately patent.
The orbits and soft tissues are grossly unremarkable. The paranasal sinuses
and mastoid air cells are clear. The bony calvaria appears intact.
IMPRESSION:
Interval stability in size and morphology of the left intraparenchymal
hematoma involving the left frontal and left temporal parietal regions,
compared to ___. Slight increase in surrounding vasogenic edema but
unchanged mild rightward midline shift and partial effacement of the left
lateral ventricle. No evidence of new intracranial hemorrhage.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fever, hemorrhagic stroke, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-existing left lower
lobe pneumonia has almost completely cleared. Only a small retrocardiac
opacity still persists. The pre-existing elevation of the hemidiaphragm on
the left is improved as compared to the previous image. No pleural effusion.
Unchanged appearance of the right lung and of the cardiac silhouette.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with left IPH // evaluate for extension of
bleed
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 780.4
CTDI: 54.32
COMPARISON: PET-CT scan ___
FINDINGS:
A left intraparenchymal hemorrhage which involves the frontal and
temporoparietal regions is unchanged in size from ___. Trace
subarachnoid hemorrhage along the left sylvian fissure is unchanged. There is
persistent vasogenic edema and mass effect with effacement of the left lateral
ventricle. Minimal left-to-right shift of normally midline structures is not
significantly changed from the prior study. There is no new focus of
intracranial hemorrhage or vascular territorial infarction.
The basal cisterns appear patent. The sulci and ventricles are unchanged in
size and configuration.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
Large left intraparenchymal hemorrhage is unchanged in appearance from CT on
___. No no evidence of hemorrhage or infarction.
Radiology Report
HISTORY: Left intraparenchymal hemorrhage.
COMPARISON: Multiple prior head CTs, most recently of ___.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformations, and
thin slice bone algorithm reconstructions were reviewed.
CTDIvol: 54 mGy.
DLP: 829 mGy-cm.
FINDINGS:
Intraparenchymal hemorrhage involving the left frontal and temporoparietal
lobes is similar in extent to ___, and may be slightly less dense.
The hemorrhagic component involving the left frontal lobe measures 26 x 17 mm,
previously 28 x 15 mm. Edema surrounding the intraparenchymal hemorrhage is
similar in extent to prior. Small subarachnoid blood products within the left
sylvian fissure are similar to prior. Rightward shift of the normally midline
structures, and mass effect on the left midbrain and left lateral ventricle,
with dilatation of the right lateral ventricle, are unchanged. No evidence of
large acute territorial infarction. No focal osseous abnormalities are
identified. The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear.
IMPRESSION:
Stable appearance of large left intraparenchymal hemorrhage and associated
mass effect.
Radiology Report
ABDOMEN
INDICATION: Pain, evaluation for acute process.
COMPARISON: No direct comparison available.
FINDINGS: No free intra-abdominal air. Several foreign bodies, obviously
clothing, project over the mid abdomen. Moderately distended stomach. Stool
in the rectal ampulla as well as in the descending colon. Gas filling of the
remaining intestinal component, without evidence of distention or air-fluid
levels. No evidence of wall thickening.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with iPh // Eval for stability of the bleed
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 780.44 mGy-cm
CTDI: 53.84
COMPARISON: CT of the head on ___
FINDINGS:
An intraparenchymal hemorrhage involving the left frontal and temporoparietal
lobes is similar in extent to ___. The overall attenuation of the
lesion is slightly less, but largely unchanged from the prior study. There is
associated vasogenic edema with narrowing of the left lateral ventricle,
unchanged in appearance. Calcifications within the left basal ganglia are
unchanged. There is no evidence of large acute territorial infarction. The
visualized osseous structures are unchanged with no abnormalities identified.
The paranasal sinuses, mastoid air cells and middle ear cavities are clear.
Atherosclerotic mural calcifications of the internal carotid arteries are
noted.
IMPRESSION:
Large left intraparenchymal hemorrhage with associated mass effect is largely
unchanged from the prior study.
Radiology Report
HISTORY: Intraparenchymal hemorrhage, evaluation for pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Previously noted left basilar opacity has continued to improve with minimal
left basilar atelectasis persisting. No new consolidations are identified.
Cardiac and mediastinal contours appear stable. No acute fractures are
identified.
IMPRESSION:
Resolution of left lower lobe pneumonia with no evidence of a new infectious
process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with left IPH // ASSESS size of bleed (on
anticoagulation now)
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: ___ MGy-cm
COMPARISON: ___.
FINDINGS:
There is no significant interval change. Involving the left cerebral
hemispheric hematoma and surrounding edema again seen. Mass effect on the left
lateral ventricle and dilatation of the right lateral ventricle again seen.
There is no new area of hemorrhage.
IMPRESSION:
Stable appearance of the evolving hematoma compared with ___. No
significant new abnormalities are seen.
Radiology Report
INDICATION: Fall while on Coumadin.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal, and thin-section bone reconstruction algorithm
images were prepared.
COMPARISON: NECT of the head, ___ and ___.
FINDINGS: There is new subarachnoid hemorrhage in the left insular region
extending into the Sylvian fissure (2:15). There is also small amount of
hemorrhage in the atria of the right lateral ventricle (2:14). Prominence of
the ventricles and sulci are stable from ___ and are most
consistent with global atrophy. The basal cisterns are patent and gray-white
matter differentiation is preserved. There is no fracture. The globes are
intact. The visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the left insular region.
2. Small amount of intraventricular hemorrhage in the right lateral
ventricle. No hydrocephalus.
3. No mass effect. Stable ventriculomegaly.
Radiology Report
INDICATION: Fall with head trauma and subarachnoid hemorrhage. Evaluation
for fracture.
TECHNIQUE: MDCT images were obtained from the skull base to the T3 level.
Coronal and sagittal reformations were prepared.
COMPARISON: None.
FINDINGS: There is no fracture or malalignment of the cervical spine. The
atlanto-occipital/axial articulations are intact. There are mild multilevel
degenerative changes throughout the cervical spine. There is no prevertebral
soft tissue edema. There is no cervical lymphadenopathy. The thyroid gland
is unremarkable. The visualized lung apices are noteworthy only for
centrilobular and paraseptal emphysema.
IMPRESSION: No acute fracture or malalignment of the cervical spine.
Radiology Report
INDICATION: Subarachnoid hemorrhage and intraventricular hemorrhage after a
fall, on Coumadin. Followup NECT.
TECHNIQUE: Contiguous axial images were obtained through the brain without IV
contrast. Contiguous axial images were obtained through the brain without IV
contrast. Coronal, sagittal and thin section bone reconstruction algorithm
images were prepared.
COMPARISON: NECT of the head from 14:48 on ___.
FINDINGS: Subarachnoid hemorrhage within the left insular region extends
slightly into the sylvian fissure and is stable from NECT of the head from
three hours ago. A small amount of intraventricular hemorrhage in the atrium
of the right lateral ventricle is also stable. Ventriculomegaly is unchanged
and there is no evidence of obstructive hydrocephalus. The ventricles and
sulci are prominent, consistent with global atrophy. The basal cisterns are
patent and gray-white matter differentiation is preserved. There is no
fracture. The visualized paranasal sinuses, mastoid air cells and middle ear
cavities are clear.
IMPRESSION: Stable left insular region subarachnoid hemorrhage as well as a
small amount of intraventricular hemorrhage in the right lateral ventricle.
Radiology Report
INDICATION: ___ female with subarachnoid hemorrhage, on treatment
with Coumadin. Evaluate for progression.
COMPARISON: Head CT performed approximately 15 hours prior to this exam as
well as admission head CT performed on ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without administration of IV contrast. Coronal, sagittal and thin slice bone
reformats were generated.
DLP: 892 mGy-cm.
CTDI: 54.98 mGy.
FINDINGS: Compared with prior examination, there has been development of
lobulated appearing foci of hemorrhage subjacent to the sulcal subarachnoid
blood in the Sylvian fissure compatible with hemorrhagic contusions in the
setting of trauma. The two main foci measure 1.5 x 1.0 cm (2:16) and 1.4 x 0.9
cm (2:14) and show minimal peripheral edema, further confirming
intraparenchymal location.
Otherwise, there is no new area of hemorrhage, edema, mass, mass effect, or
large territorial infarction. The ventricles and sulci are prominent,
suggesting age-related involutional changes. Calcification of the bilateral
basal ganglia is an incidental finding. There is preservation of gray-white
matter differentiation and the basal cisterns are patent.
No fracture is identified. The paranasal sinuses, mastoid air cells and
middle ear cavities are clear. There is minimal atherosclerotic calcification
of the carotid siphons.
IMPRESSION: Interval development of likely focus of parenchymal hemorrhage,
subjacent to the sites of subarachnoid hemorrhage along the left sylvian
fissure, compatible with hemorrhagic contusions. Associated mild peripheral
edema is seen about these foci of hemorrhage but there is no evidence of mass
effect.
COMMENT: These findings were communicated to Ms ___ by Dr. ___ on
___ at 9:20 a.m. via telephone, immediately after discovery.
Radiology Report
HISTORY: Status post fall with subarachnoid hemorrhage. Induration near left
hip.
COMPARISON: None.
FINDINGS:
There is soft tissue edema overlying the left hip. No left hip joint effusion
is demonstrated.
No fluid collection is identified.
IMPRESSION:
Soft tissue swelling overlying the left hip, with no significant hematoma
identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with Hep C, mechanical AVR and MVR here s/p
fall found tohave SAH, heparin drip restarted ___ // interval change, increase
in bleed; please get ___ AM
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 780 mGy-cm
CTDI: 55.7 mGy
COMPARISON: Multiple prior exams, most recently ct head from ___.
FINDINGS:
Compared to the prior exam, there has been no significant change. Again seen
are two foci of intraparenchymal contusions within the left parietal region
adjacent to the sylvian fissure measuring 13 x 10 mm (2:13) and 15 x 7 mm
(2:10). Subarachnoid hemorrhage in the adjacent sulci are unchanged. There is
no new intraparenchymal hemorrhage. Basal ganglia calcifications are noted.
Ventricles and sulci remain prominent consistent with atrophy. The basilar
cisterns are patent. The visualized paranasal sinuses, mastoid air cells and
middle ear cavities are clear. The bones are unremarkable.
IMPRESSION:
No significant change since the previous exam in subarachnoid hemorrhage in
the left sylvian fissure and two adjacent foci of intraparenchymal hemorrhage.
Radiology Report
INDICATION: ___ female with subarachnoid hemorrhage on mechanical
valve, on Lovenox. With increased lethargy. Evaluate for bleed.
COMPARISONS: CT head from ___ and ___ and ___.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DLP: 780.4 mGy-cm.
FINDINGS: Compared to the prior exam, there is no large increase in the
intraparenchymal hemorrhage involving the left temporoparietal region
measuring approximately 4.9 x 3.3 cm in maximal dimension. There is increased
subarachnoid hemorrhage within the left frontal sulci (2:10). Edema
surrounding the hemorrhage has increased significantly since the previous exam
and there is now mass effect upon the left lateral ventricle which is
compressed. The basilar cisterns are patent. The visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear. Bones are
intact and there is no acute fracture.
IMPRESSION: Significant increase in size of a left temporoparietal
intraparenchymal hemorrhage with increase in subarachnoid hemorrhage involving
the left frontal sulci compared to the recent prior exam. There is now
increasing mass effect on the left lateral ventricle which is compressed.
These findings were discussed with ___ by Dr. ___ telephone
at approximately 4:15 p.m.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after right subclavian
central venous line insertion.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The right central venous line tip is at the level of cavoatrial junction. The
NG tube tip is in the stomach. The heart size and mediastinum as well as the
replaced valve are in unchanged position. There is no evidence of
pneumothorax or interval development of substantial pleural effusion. Minimal
bibasilar atelectasis is noted.
Radiology Report
HISTORY: Left frontal intraparenchymal hemorrhage.
COMPARISON: Non-contrast head CT ___, 3:40 p.m.
TECHNIQUE: Contiguous axial MDCT images were obtained of the head without
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone reformats.
DLP: 780.44 mGy-cm.
FINDINGS:
CT HEAD WITHOUT CONTRAST: Compared to yesterday's examination, there is
re-demonstration of a large left temporoparietal intraparenchymal hemorrhage
measuring 4.9 x 3.3 cm appearing centered within the external capsule, overall
unchanged in size with re-demonstration of a small amount of subarachnoid
hemorrhage within the adjacent sylvian fissure and adjacent frontal sulci.
Additional punctate hyperdense focus of hemorrhage in the anterior left
frontal cortex (2:14) is unchanged. Associated mass effect with effacement of
the left lateral ventricle is unchanged. There is no significant shift of
midline structures. There is no new focus of hemorrhage or infarct. The
basal cisterns remain patent. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear.
IMPRESSION: No significant change in left frontotemporoparietal
intraparenchymal hemorrhage, centered in the external capsule, with
subarachnoid blood layering within the sylvian fissure and adjacent frontal
sulci with unchanged degree of mass effect, effacing the left lateral
ventricle. Additional punctate focus of hemorrhage in the left anterior
frontal cortex measuring 4 mm is unchanged. No new focus of hemorrhage or
infarct.
Radiology Report
INDICATION: Patient with history of intraparenchymal subarachnoid hemorrhage.
Assess for interval change.
COMPARISONS: ___.
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 a left intraparenchymal hemorrhage which involves frontal, and
temporoparietal regions. It measures 5 x 3.1 cm in maximum dimension,
unchanged in size. Subarachnoid hemorrhage layering along the sylvian
fissures were demonstrated, unchanged. There is surrounding vasogenic edema
and persistent mass effect with effacement of the left lateral ventricle.
There is no shift of normally midline structures. No new focus of
intracranial hemorrhage is detected. There is no vascular territorial
infarction. The basal cisterns remain patent. There is no evidence of
herniation. The sulci and ventricles are unchanged in size and configuration.
Orbits are unremarkable. Imaged paranasal sinuses and mastoid air cells are
well aerated.
IMPRESSION:
In comparison to ___ exam, there is no interval change in known left
intraparenchymal hemorrhage, as described above. There is surrounding
vasogenic edema and mass effect on the left lateral ventricle without
significant mass effect. Subarachnoid hemorrhage layering in the sylvian
fissure and the left sylvian fissure is unchanged. No new focus of
intracranial hemorrhage.
Radiology Report
AP CHEST 5:42 A.M. ON ___
HISTORY: ___ woman with hypoxia.
IMPRESSION: AP chest compared to more ___:
Severe opacification in the left hemithorax is new. The abnormality obscures
much of the left lower lung. I cannot tell whether it is pulmonary alone or
combination of pulmonary and pleural abnormality. This could be a large
pneumonia or a left lower lobe collapse as well as substantial left pleural
effusion, most likely hemothorax in this patient. I discussed these findings
by telephone with Dr. ___ clinical profile suggests acute lobar
collapse. Imaging confirmation can be provided by chest CT scanning if
appropriate.
Mild pulmonary vascular congestion suggests elevated left atrial pressure.
Patient has had median sternotomy and two cardiac valve replacements. There
is no pulmonary edema.
Radiology Report
REASON FOR EXAMINATION: Coarse breathing, suspected pneumonia.
AP radiograph of the chest was reviewed in comparison to ___.
Cardiomediastinal silhouette including the two replaced valves is stable. The
assessment of the left lung demonstrates opacification of the mid and lower
lung, unchanged since the prior study and concerning for interval development
of infectious process given the absence of the findings on ___.
Aspiration or non-aspiration pneumonia are both a possibility. Combination of
pleural effusion and lobe collapse should be considered, but the normal
pattern of the airways would make the collapse less likely.
Radiology Report
AP CHEST, 5:49 AM, ___
HISTORY: ___ woman after CVA. Readmitted for respiratory distress.
IMPRESSION: AP chest compared to ___:
Some volume loss has developed in the very large consolidation in the left
lower lobe, probably due to aspiration pneumonia and some airway obstruction
due to retained secretions. Right lung clear. Heart size top normal. The
patient has had aortic and mitral valve replacements. No pneumothorax. There
is some pleural effusion on the left, but not substantial.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old woman with intraparenchymal hemorrhage; evaluate for
progression // ___ year old woman with intraparenchymal hemorrhage; evaluate
for progression
TECHNIQUE: Contiguous axial images were obtained through the head without the
administration of intravenous contrast. Coronal and sagittal reformatted
images as well as thin section images in a bone window algorithm were
generated and reviewed.
DOSE: DLP: 892 mGy-cm; CTDI: 56 mGy
COMPARISON: Non contrast head CT last performed on ___ with multiple
prior head CTs dating back to ___.
FINDINGS:
HEAD CT: The left intraparenchymal hemorrhage which involves the frontal and
temporoparietal regions is slightly decreased in size from ___,
measuring 58 x 43 mm on sagittal imaging (previously 65 x 40 mm on a similar
slice selection). Trace subarachnoid hemorrhage along the left sylvian
fissure is unchanged. There is similar extent of surrounding vasogenic edema
and persistent mass effect with effacement of the left lateral ventricle.
There is minimal left-to-right shift of normally midline structures, which is
not significantly changed. No new focus of intracranial hemorrhage is
detected. There is no vascular territorial infarction. The basal cisterns
remain patent. There is no evidence of herniation. The sulci and ventricles
are unchanged in size and configuration. The orbits are unremarkable. The
frontal sinuses are aplastic. The imaged paranasal sinuses, middle ear
cavities and mastoid air cells are well aerated bilaterally. The bony
calvaria appear intact.
IMPRESSION:
Mild interval decrease in size of large left intraparenchymal hemorrhage in
comparison to the most recent prior noncontrast head CT of ___ with
unchanged extent of subarachnoid hemorrhage in the left sylvian fissure.
Similar minimal left-to-right midline shift.
Radiology Report
INDICATION: ___ year old woman with hemorrhagic contusion, now expanding;
cachectic,malnourished, anemic, renal failure, evaluate for mass or
malignancy.
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis were without the
administration of IV contrast. Oral contrast was given. Coronal and axial
reformatted images were also generated for review.
DOSE: 382 mGy-cm
COMPARISON: MRI abdomen from ___.
FINDINGS:
Assessment of the soft tissue structures and vasculature is somewhat limited
without the administration of IV contrast.
CT THORAX: Please see separate report from CT chest performed on the same day
for discussion of findings within the thorax.
LIVER: The liver is grossly unremarkable. There is no intrahepatic biliary
duct dilatation. The gallbladder is unremarkable.
PANCREAS: The pancreas does not demonstrate focal lesions, peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys are grossly remarkable. A 5mm non-obstructing stone is
seen in the lower pole of the left kidney. There is no hydronephrosis or
perinephric abnormalities.
GI TRACT: The stomach, duodenum, and small bowel are grossly unremarkable,
without evidence of wall thickening or obstruction. The colon is non-dilated
without obstructive lesions. There is mild thickening of the colonic wall
which may be due to third spacing. The appendix is not visualized. Enteric
contrast is see throughout the GI tract into the and rectum.
VASCULAR: The aorta contains moderate amount of atherosclerotic
calcifications extending into the common iliac arteries but is normal in
caliber without aneurysmal dilatation. The IVC and major abdominal vessel
patency cannot be assessed on a noncontrast enhanced study.
RETROPERITONEUM AND ABDOMEN: There is no overt retroperitoneal or mesenteric
lymph node enlargement. No free air or abdominal wall hernias is noted. There
is a small amount of ascites.
PELVIC CT: The urinary bladder and terminal ureters are grossly unremarkable.
No definite pelvic wall or inguinal lymph node enlargement is seen. There is a
small amount of pelvic free fluid.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present.
IMPRESSION:
1. Limited assessment due to lack of IV contrast. No definite mass is
identified within the abdomen or pelvis.
2. Small amount of free fluid within the abdomen and pelvis.
3. 5mm non-obstructing stones in the lower pole of the left kidney.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL
temperature: 98.2
heartrate: 77.0
resprate: 18.0
o2sat: 100.0
sbp: 161.0
dbp: 88.0
level of pain: 1
level of acuity: 2.0 | The patient is a ___ with history of hepatitis C, CKD, anemia,
on anticoagulation for mechanical AVR/MVR who was admitted after
mechanical fall with head strike on ___ and finding of small
left insular SAH with small IVH component. At that time INR
was 3.3. She was admitted to Neurosurgery and coumadin was held
without being actively reversed (approved by cardiology
consult). Serial NCHCTs were done which were stable until ___
when there was evidence of a small intraparenchymal hemorrhagic
contusion along with the SAH. This was felt to be a normal
sequelae of her head strike.
She was transferred to the medicine service on ___. Her INR
that day was 1.8 and she was started on a heparin gtt with
2900unit bolus as a bridge to coumadin given her mechanical
valves. Both the heparin with bolus was approved by the
neurosurgical team. The night of ___, she had one recorded
elevated PTT to 140s, but subsequent PTTs were in the goal range
of 60-80. That day she was also transfused 1 unit PRBC for
anemia.
The following day ___, her heparin gtt was transitioned to
lovenox 30mg SQ given the plan to discharge her home. Prior to
discharge, she was noted to be lethargic. Around 130pm, she was
even more lethargic and with slurred speech. NCHCT was done at
3pm which showed increasing left temporoparietal hemorrhage,
SAH, and mass effect on the left lateral ventricle.
Stroke neurology saw the patient urgently and found her
hypertensive to 190s/100s, lethargic yet responsive with a right
facial droop, left gaze preference, right sided weakness (right
arm ___, and right leg ___, bilateral upgoing toes. She was
urgently treated with Hydralazine and Labetalol IV doses while
urgently transfering to the NICU under the Neurology service.
BP was controlled (SBP<150) with a nicardipine gtt. No active
reversal was needed as INR was 1.1 and PTT was 34. Serial NCHCTs
were done to reevaluate her IPH and SAH. All anticoagulants were
stopped. Over several days, her exam improved, she became more
attentive, with no gaze preference, and improved strength on the
right.
On ___, she was transferred to the floor. However she
desaturated upon lying flat to the ___ and was placed on a
non-rebreather. Pulmonology performed an ultrasound which showed
atelectasis in the left lung, extensive, as seen on chest x ray
in the morning (likely due to mucus plugging). She was
transferred to the ICU. She was given incentive spirometry and
did well, by the end of the day she was saturating well on 3L
nasal cannula. By ___, her chest x ray was improved and she
saturated well on room air. She was then transferred back to the
floor.
On the floor she did well except that she wasn't taking adequate
oral intake. She was felt to be cachectic and had lost lots of
weight over the previous year. She had anemia persistently
throughout the hospital course which was likely in part due to
her chronic renal failure and hepatitis C, but otherwise was of
unclear etiology. We did a CT abdomen/pelvis to look for
malignancy as a possible cause but did not find anything
concerning for cancer. We had nutrition come see her and they
recommended Ensure shakes, which were not low potasssium.
Unfortunately, she became hyperkalemic, likely secondary to the
Ensure and her known chronic renal failure, with potassium
peaking at 7.0 on ___. She was given kayexalate, calcium
gluconate and insulin and her potassium decreased back to normal
levels. Her EKG done at the time of the hyperkalemia showed
peaked T-waves, which improved when her potassium improved. The
Ensure shakes were stopped.
She also became slightly more somnolent around this time, but
her UCx returned positive on ___, so she was put on a three day
course of ceftriaxone. Her mental status improved with
treatment of the UTI.
Of note, she was started on warfarin on ___ at a low dose of
2.5. After three days, her INR had still not gone above 1.0, so
she was also started on a heparin gtt on ___ to ensure
appropriate anticogulation given her two mechanical valves. Her
coumadin was increased until it was 7.5mg, which on ___ brought
her INR to 2.1. Her heparin gtt was continued as her goal INR
was 2.5-3.5. She had a NCHCT to ensure no increased bleeding
once her INR was above 2.0, which showed a stable appearance of
her hemorrhage. She was sent to rehab with a plan to continue
her bridge to warfarin with goal INR 2.5-3.5. She will need her
INR checked daily until it is in range. She will need her PTT
checked at least every 12 hours and adjusted to maintain goal
range of 50-70.
In addition, her BUN and Cr have fluctuated during this
admission. She has known CKD. At discharge her BUN was 43 and
creatinine was 1.5. These will need to be monitored at least
twice a week to ensure that she is not having worsening renal
failure.
====================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes after initial SAH, DVT ppx was restored, but after
admission to ICU, ppx was held off until ___ when SQ heparin
was restarted.
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ] |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Quinidine Hcl
Attending: ___.
Chief Complaint:
hemorrhagic shock
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Mr. ___ is a ___ year old M w/ hx of atrial fibrillation,
HFpEF, gout, HLD, and ___ presenting with black stools. He
underwent an esophageal RFA procedure on ___. For the past
two days, he has been having dark red-black stools and
lightheadedness. He saw his cardiologist this week who decreased
his nebivolol for lightheadedness. He did take his bnebivolol
and verapamil this morning. He last took his Rivaroxiban last
night. He is not on aspirin. he denies any CP, SOB, current
lightheadedness, abdominal pain, N/V, hematemesis, hemoptysis.
In the ED, his vitals were notable for an acute drop in blood
pressure to the ___. Exam notable for tachycardia and being
unwell appearing. His Hgb 15 -->9. He was given 3 units pRBCs
and
500 cc LR. He was started on norepinephrine peripherally and IV
pantoprazole BID. GI was consulted who recommended EGD. He was
given one dose of 10 mg IV metoclopramide.
In the MICU, he was intubated for his EGD. Intubation was
uncomplicated. EGD showed bleeding at the site of his ___
procedure. Hemogel was placed and hemostasis was achieved.
Past Medical History:
HTN
A fib
___ esophagus s/p RFA ablation w c/b hemorrhagic shock
HFpEF
HTN
HLD
Insomnia
Social History:
___
Family History:
No coagulopathy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98 HR 81 BP 93/63 RR 19 SPO2 100% on 100% FiO2
GEN: Middle-aged male sitting up in bed in no acute distress.
Alert and interactive
HEENT: Dry MM. PERRL. EOMI. No facial droop.
NECK: JVP not visible at 90 degrees
CV: RRR. Nl s1/s2. No m/r/g
RESP: CTAB. no w/r/r
GI: Soft. NT. ND. Normoactive BS.
MSK: Normal muscle tone and bulk
SKIN: Erythematous. Warm. Cap refill brisk.
NEURO: AAOx3. Walks on own. CN grossly intact.
DISCHARGE PHYSICAL EXAM:
========================
GEN: Middle-aged male sitting up in bed in no acute distress.
Alert and interactive
HEENT: Dry MM. PERRL. EOMI. No facial droop.
NECK: JVP not visible at 90 degrees
CV: RRR. Nl s1/s2. No m/r/g
RESP: CTAB. no w/r/r
GI: Soft. NT. ND. Normoactive BS.
MSK: Normal muscle tone and bulk
SKIN: Erythematous. Warm. Cap refill brisk.
NEURO: AAOx3. Walks on own. CN grossly intact.
Pertinent Results:
ADMISSION LABS
==============
___ 12:39PM BLOOD WBC-11.8* RBC-2.95* Hgb-9.4* Hct-29.5*
MCV-100* MCH-31.9 MCHC-31.9* RDW-14.1 RDWSD-51.8* Plt ___
___ 12:39PM BLOOD Neuts-70.0 ___ Monos-6.8 Eos-0.3*
Baso-0.3 Im ___ AbsNeut-8.26* AbsLymp-2.59 AbsMono-0.80
AbsEos-0.03* AbsBaso-0.04
___ 12:39PM BLOOD ___ PTT-26.6 ___
___ 04:45PM BLOOD ___ 12:39PM BLOOD Glucose-108* UreaN-53* Creat-0.9 Na-140
K-4.2 Cl-108 HCO3-19* AnGap-13
___ 12:39PM BLOOD Glucose-108* UreaN-53* Creat-0.9 Na-140
K-4.2 Cl-108 HCO3-19* AnGap-13
___ 12:39PM BLOOD cTropnT-<0.01
___ 12:39PM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8
___ 01:09PM BLOOD Glucose-106* Lactate-1.7 Creat-1.0 Na-137
K-3.9 Cl-112* calHCO3-20*
___ 01:09PM BLOOD Hgb-10.3* calcHCT-31
DISCHARGE LABS
==============
___ 05:23AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.6* Hct-29.5*
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.9 RDWSD-51.8* Plt ___
___ 05:23AM BLOOD Plt ___
___ 05:23AM BLOOD Glucose-103* UreaN-19 Creat-0.8 Na-145
K-4.4 Cl-110* HCO3-23 AnGap-12
IMAGING & STUDIES
================
___ CXR
Comparison to ___. Stable low lung volumes. Stable
moderate cardiomegaly with mild elongation of the descending
aorta. No pleural effusions. No pulmonary edema. No
pneumonia. The hilar and mediastinal contours are unremarkable.
___ CXR
FINDINGS:
An endotracheal tube tip projects 3.0 cm superior to the carina.
Low lung volumes result in crowding of the bronchovascular
structures and accentuation of heart size. There is mild
atelectasis. The lungs are otherwise clear. The costophrenic
angles are excluded from the field of view. Heart size is
moderately enlarged. There is mild aortic arch calcification.
The mediastinal silhouette is otherwise unremarkable. A soft
tissue anchor projects over the right humeral head.
IMPRESSION: An endotracheal tube tip projects 3.0 cm superior
to the carina.
___ EGD
-Large semi-circumferential ulcer was seen at the GE junction
consistent with post-RFA ulcer. An adherent clot was seen. After
irrigation and suction, friable mucosa was identified. There was
spontaneous oozing in setting of contact from the scope
-Erythema in the antrum compatible with gastritis.
-Normal mucosa in the whole examined duodenum.
RECOMMENDATIONS:
- ___ extubate patient from GI standpoint.
- Continue high dose PPI BID.
- Once extubated and no bleeding overnight, may advance diet as
tolerated.
- If safe from cardiovascular standpoint, as per primary team,
holding Xarelto for next 5 days will decrease risk of bleeding,
duration of holding Xarelto after discussing with primary
team/cardiologist.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Testosterone Gel 1% 50 mg TP DAILY
2. Furosemide 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. AcetaZOLamide 125 mg PO Q24H
5. Rivaroxaban 20 mg PO DAILY
6. Bystolic (nebivolol) 20 mg oral DAILY
7. Allopurinol ___ mg PO DAILY
8. Verapamil SR 120 mg PO Q24H
9. Atorvastatin 80 mg PO QPM
10. Ranitidine 300 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Zolpidem Tartrate 5 mg PO QHS
13. loteprednol etabonate 0.5 % ophthalmic (eye) Q4H:PRN
Discharge Medications:
1. Verapamil SR 180 mg PO Q24H
RX *verapamil 180 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. AcetaZOLamide 125 mg PO Q24H
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bystolic (nebivolol) 20 mg oral DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Furosemide 20 mg PO DAILY
8. loteprednol etabonate 1 % ophthalmic (eye) BID
9. Omeprazole 40 mg PO BID
10. Testosterone Gel 1% 50 mg TP DAILY
11. Zolpidem Tartrate 5 mg PO QHS
12. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
#Upper GI Bleeding
Secondary Diagnosis:
====================
#Atrial fibrillation
#Hypertension
___ esophagus
#Heart failure with preserved ejection fraction
#Hyperlipidemia
#Insomnia
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 chf, GI bleeding, crackles in lungs// chf?
chf?
IMPRESSION:
Comparison to ___. Stable low lung volumes. Stable moderate
cardiomegaly with mild elongation of the descending aorta. No pleural
effusions. No pulmonary edema. No pneumonia. The hilar and mediastinal
contours are unremarkable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with a fib, HTN, HFpEF p/w GIB, getting
emergently scoped// evaluate ETT placement
TECHNIQUE: Frontal view of the chest
COMPARISON: Chest radiographs between ___ and ___
FINDINGS:
An endotracheal tube tip projects 3.0 cm superior to the carina. Low lung
volumes result in crowding of the bronchovascular structures and accentuation
of heart size. There is mild atelectasis. The lungs are otherwise clear.
The costophrenic angles are excluded from the field of view. Heart size is
moderately enlarged. There is mild aortic arch calcification. The
mediastinal silhouette is otherwise unremarkable. A soft tissue anchor
projects over the right humeral head.
IMPRESSION:
An endotracheal tube tip projects 3.0 cm superior to the carina.
Gender: M
Race: WHITE
Arrive by OTHER
Chief complaint: Dizziness, Melena
Diagnosed with Gastrointestinal hemorrhage, unspecified, Hypotension, unspecified, Dizziness and giddiness
temperature: 96.7
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 81.0
dbp: 48.0
level of pain: 0
level of acuity: 1.0 | PATIENT SUMMARY
===============
Mr. ___ is a ___ man with chronic A fib on rivaroxaban,
congestive heart failure, gout, hyperlipidemia, and other issues
admitted with GI bleeding after having undergone radiofrequency
ablation for ___ esophagus 8 days ago (___). After the
procedure, he developed progressive light-headedness,
particularly with exertion, over the past two days. He first
presented to his Cardiologist yesterday (___) for a routine
follow-up appointment, and due to orthostatic symptoms, his
nebivolol dose was reduced to 20mg from 30mg q24h. Due to
persistent light-headedness, he presented to the Emergency
Department (___) for evaluation. He was hypotensive to the
___ systolic in the ED. Laboratory studies demonstrated a white
count of 11.8, hemoglobin of 9.4 (down from 15.4 in ___, and
platelets of 201. His INR was 1.5. Chemistry studies revealed a
bicarbonate of 19, BUN of 53, and creatinine of 0.9. Chest x-ray
did not reveal acute cardiopulmonary abnormalities.
Gastroenterology was consulted, and plan on performing an EGD
after ICU admission. He received 500cc of crystalloid and 2
units of pRBCs, he was ordered for pantoprazole, and was
ultimately initiated on norepinephrine through a peripheral IV
for persistent hypotension. He was intubated shortly after
admission to the ICU to facilitate EGD, which demonstrated a
distal esophageal erosion / ulceration at the ___ site which was
sprayed with hemogel. He was immediately extubated after EGD
without issues. He was transferred to the medicine ward and able
to be discharged after stabilization of his heart rates.
TRANSITIONAL ISSUES
===================
[] Holding home rivaroxaban until ___
[] Recheck CBC at next visit with PCP
[] Continue twice daily PPI until follow-up with GI
[] Continue soft diet until ___
[] Avoid NSAIDs for the next week, use Tylenol as needed for
pain
[] Patient to follow-up with Dr. ___
CODE STATUS: Full code
___ (Wife) ___
ACUTE/ACTIVE ISSUES
==================
#Acute upper GI bleed
#Hemorrhagic shock
Hemorrhagic shock ___ bleed demonstrated an esophageal ulcer at
the site of the radiofrequency ablation procedure he had
undergone on ___, and hemogel was applied. Briefly required
pressors in setting of intubation, but responded well to volume
resusitation. He has not had evidence of recurrent hemorrhage
and we are continuing to follow clinically for evidence of
recurrent GI bleeding, as well as following his blood counts
intermittently - there has been no evidence of decreasing
hemoglobin. Continued pantoprazole, ranitidine (which is a home
medication), and we are holding rivaroxaban for ___ days.
#Acute respiratory failure
He was intubated to facilitate EGD yesterday, and was
immediately extubated post-procedure. We are following his work
of breathing, oxygenation, and respiratory status to guide the
need for further interventions. He is on ambient air.
#Leukocytosis
Elevated on presentation to 11.8. No systemic or localizing s/sx
of infection. Suspect hemoconcentration in setting of
hemorrhagic shock. Normalized without interventions, no
indication for antibiotics at this time.
#Atrial fibrillation with RVR to 150s
His home nodal blockade agents were held on admission due to
concern for upper GI bleeding. His home regimen was restarted
and he was able to tolerate it well prior to discharge. He was
not in RVR at discharge. His outpatient cardiology team was
notified of the decision to hold rivaroxaban for 5 to 7 days
until ___.
#HTN
#HFpEF
Held his anti-hypertensives initially given bleeding, and then
while re-introducing beta-blocker as noted above.
CHRONIC/STABLE ISSUES
====================
#OSA: Continued home ___ CPAP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Right lower quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M otherwise healthy presenting with RLQ abdominal pain
that began ___. Patient states that it was first located in
the epigastric region and then subsequently localized to the
RLQ. He denies any associated fevers, chills, nausea, vomiting,
or anorexia. He denies any recent changes in his bowel habits.
He denies any history of prior abdominal surgeries or any recent
sick contacts.
Past Medical History:
PMHx: none
PSHx: removal of adenoids
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T 97.1, HR 64, BP 157/98, RR 18 100% RA
Gen: well appearing, NAD
CV: RRR, palpable peripheral pulses
P: nonlabored breathing on room air
GI: soft, nontender, nondistended; mild TTP in RLQ; no rebound
or
guarding; no tap or shake tenderness
Ext: WWP, no CCE
Discharge Physical Exam:
VS: 97.5 PO 114 / 77 68 98% RA
Gen: Awake, alert, sitting up in bed. Pleasant and interactive.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, non-tender, non-distened.
Ext: Warm and dry. no edema. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 05:04AM BLOOD WBC-10.0 RBC-4.98 Hgb-15.0 Hct-42.5
MCV-85 MCH-30.1 MCHC-35.3 RDW-11.6 RDWSD-35.5 Plt ___
___ 02:25PM BLOOD WBC-7.7 RBC-5.34 Hgb-16.4 Hct-45.8 MCV-86
MCH-30.7 MCHC-35.8 RDW-11.8 RDWSD-36.5 Plt ___
___ 05:04AM BLOOD ___ PTT-28.9 ___
___ 05:04AM BLOOD Glucose-98 UreaN-11 Creat-1.1 Na-138
K-3.8 Cl-101 HCO3-26 AnGap-15
___ 02:25PM BLOOD Glucose-90 UreaN-15 Creat-1.1 Na-140
K-4.6 Cl-101 HCO3-28 AnGap-16
___ 05:04AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 06:00PM BLOOD Lactate-1.1
___ CT A/P:
1. Findings consistent with acute appendicitis ; the distal
appendix is
dilated to 12 mm, fluid-filled, and with thickened, hyperemic
wall. Mild
adjacent periappendiceal fat stranding. No drainable fluid
collection or
extraluminal gas.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
do not exceed 4 grams/ 24 hours
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*18 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*27 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: NO_PO contrast; History: ___ with 3 days of worsening RLQ pain,
tender at ____PO contrast // r/o appendicitis
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: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung 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 collapsed.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. No bowel obstruction or bowel
wall thickening is seen. The distal appendix is dilated to 12 mm,
fluid-filled, and with thickened hyperemic wall. There is mild adjacent
periappendiceal fat stranding. Findings are consistent with acute
appendicitis. No drainable fluid collection or extraluminal gas is seen.
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. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Findings consistent with acute appendicitis ; the distal appendix is
dilated to 12 mm, fluid-filled, and with thickened, hyperemic wall. Mild
adjacent periappendiceal fat stranding. No drainable fluid collection or
extraluminal gas.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___
at 16:15 on ___ via telephone.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RLQ abdominal pain, Transfer
Diagnosed with Unspecified acute appendicitis
temperature: 97.1
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 157.0
dbp: 98.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with right lower quadrant/epigastric pain
for 3 days. Denies associated fever, chills, nausea, vomiting,
or change in bowels. CT abdomen pelvis was consistent with acute
appendicitis. Risks and benefits of operative versus medical
management with antibiotics was discussed and the patient opted
for medical mangagment. He was made NPO, given IV antibiotics,
and admitted to the floor for monitoring.
On HD2 he remained afebrile, hemodynamically stable, and
abdominal pain improved. White blood cell count was 10.0 from
7.7. His diet was progressively advanced to regular with good
tolerability with normal bowel function.
He was discharged to home on HD2 to complete a 10 day course of
antibiotics. At the time of discharge, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ibuprofen / morphine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient began having RUQ pain and episodes of emesis on ___.
The pain was initially ___ and woke her up from sleep with
large amounts of green/yellow vomiting. The pain subsequently
decreased to ___ and intermittently increased to ___. The
pain was noted to be worse after eating. Patient denied nausea
and has been passing flatus. Patient was unsure of her
temperature but didn't think she had a fever. Her last bowel
movement was ___.
Past Medical History:
Past Medical History:
1. Hypertension.
2. Migraine headaches.
3. Gastroesophageal reflux.
4. Mild sleep-disordered breathing based on recent sleep study.
5. Vitamin D deficiency.
6. Mild esophagitis with gastritis secondary to hemetemesis.
(Last endoscopy was done at ___ on ___, which
revealed irregular Z-line at the GE junction, normal mucosa of
the stomach, normal mucosa of the duodenum. Biopsies were taken
which just revealed some mild active esophagitis.)
7. Weight related knee problems for which she is followed here
at ___.
Past Surgical History:
1. Endoscopy on ___.
2. D&C in ___.
3. Oral surgery for infection in ___ at ___.
Social History:
___
Family History:
Her family history is noted for a father living with
hypertension, coronary artery disease and stroke; mother living
with hypertension, rheumatoid arthritis and obesity (had lap
band procedure); brother with possible heart condition and
overweight; one son with obesity and another with attention
deficit disorder.
Physical Exam:
VS: 98.3 F oral, 112/76, 60, 18, 99% RA
N:A&Ox3, ___ and interactive. NAD.
C/V: afebrile. RRR. non murmur/no regurg.
Resp: Breath sounds clear to auscultation. No distress.
GI/GU: Abdomen soft, non-distended. mild tenderness in upper
gastric area with deep palpation. no rebound/gaurding.
Skin: Grossly intact.
Extremities: warm and dry. no edema. ___ pulses 2+ palpable.
Pertinent Results:
___ CT ABD & Pelvis IMPRESSION:
No evidence of obstruction, no acute intra-abdominal process.
Significant reflux of enteric contrast retrograde into the
afferent limb
extending to the duodenum. There is also contrast within the
excluded
stomach, potentially from retrograde opacification although
underlying
gastrogastric fistula is not excluded.
___ Liver/Gallbladder US Impression:
Normal appearance of the gallbladder and pancreas. No
intrahepatic biliary dilation. Normal common bile duct.
___ CHXR IMPRESSION:
No evidence of obstruction. No free air. Previously ingested
oral contrast has move distally into the colon. Contrast within
the excluded stomach as seen on prior CT may represent gastro
gastric fistula versus reflux of
contrast.
___ CT ABD & Pelvis Impression:
1. Status post Roux-en-Y gastric bypass. No evidence of small
bowel
obstruction or internal hernia. No acute process in the abdomen
or pelvis.
2. Large fecal loading throughout the colon and rectum.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. TraMADOL (Ultram) 50 mg PO BID:PRN menstrual pain
4. Albuterol Sulfate (Extended Release) 180 mcg PO Q4H wheeze
5. Sumatriptan Succinate 40 mg PO ONCE MR1 migraine
6. Fluoxetine 10 mg PO DAILY
7. Chlorthalidone 25 mg PO DAILY
8. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO)
9. Vitamin D 5000 UNIT PO DAILY
10. Clindamycin 1% Solution 1 Appl TP DAILY
Discharge Medications:
1. TraMADOL (Ultram) 50 mg PO BID:PRN menstrual pain
2. Acetaminophen (Liquid) 650 mg PO Q6H
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*15 Packet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*15 Tablet Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 10 ml by mouth four times a day
Refills:*0
6. Albuterol Sulfate (Extended Release) 180 mcg PO Q4H wheeze
7. Amlodipine 10 mg PO DAILY
8. Chlorthalidone 25 mg PO DAILY
9. Clindamycin 1% Solution 1 Appl TP DAILY
10. Cyanocobalamin 1000 mcg IM/SC EVERY 4 WEEKS (MO)
11. Fluoxetine 10 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Sumatriptan Succinate 40 mg PO ONCE MR1 migraine Duration: 1
Dose
14. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ s/p roux-en-y bypass p/w bilious emesis, and RUQ abdominal
pain+PO contrast // Eval for possible stricture, obstruction
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus
technique.Coronal and sagittal reformations were performed.Oral contrast was
administered.
DOSE: Total DLP (Body) = 791 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
The lung bases are clear.
The liver, spleen, kidneys, adrenal glands, gallbladder and pancreas are
unremarkable. Oral contrast is seen within the gastric pouch and in the
efferent limb extending to the JJ anastomosis. There is also some contrast in
the jejunum distant to this anastomosis. There are no dilated loops to
suggest obstruction. There is is significant on reflux of oral contrast into
the afferent limb seen to the region of the fourth portion of the duodenum.
In addition, there is some oral contrast within the excluded portion of the
stomach. Colon is unremarkable. The appendix is not visualized, although
clip at the base of the cecum suggest prior appendectomy.
Intrauterine device seen within the uterus. Adnexae are unremarkable. There
is no free intraperitoneal fluid, free air, or intra-abdominal adenopathy.
Abdominal aorta is normal in caliber.
No focal suspicious osseous lesions. There is no fracture.
IMPRESSION:
No evidence of obstruction, no acute intra-abdominal process.
Significant reflux of enteric contrast retrograde into the afferent limb
extending to the duodenum. There is also contrast within the excluded
stomach, potentially from retrograde opacification although underlying
gastrogastric fistula is not excluded.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ s/p RNYGB ___ presents with abdominal pain and bilious
emesis // r/o gallbladder abnormalities
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis from 1 day prior
FINDINGS:
LIVER: The hepatic parenchyma appears slightly coarsened. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
Limited images of the right kidney are unremarkable.
IMPRESSION:
Normal appearance of the gallbladder and pancreas. No intrahepatic biliary
dilation. Normal common bile duct.
Radiology Report
INDICATION: ___ s/p RNYGB ___ presents with abdominal pain and bilious
emesis // assess for abnormality
TECHNIQUE: Upright and supine radiographs
COMPARISON: CT abdomen pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Oral contrast
is seen within large bowel loops. Small amount of contrast is seen in the
region of the expected excluded stomach which correlates to findings on prior
CT. There is no free intraperitoneal air. Surgical clips and chain sutures
are seen within the left upper quadrant. There is an intrauterine device seen
overlying the pelvis. No acute osseous abnormality.
IMPRESSION:
No evidence of obstruction. No free air. Previously ingested oral contrast
has move distally into the colon. Contrast within the excluded stomach as
seen on prior CT may represent gastro gastric fistula versus reflux of
contrast.
Radiology Report
INDICATION: ___ year old woman RNY bypass, persistent post-prandial pain, rule
out internal hernia.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
4) Spiral Acquisition 4.5 s, 48.9 cm; CTDIvol = 15.6 mGy (Body) DLP = 762.4
mGy-cm.
Total DLP (Body) = 764 mGy-cm.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis at the lung bases
bilaterally. There is no pericardial or pleural 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
and the portal vein is patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Heterogeneous attenuation of the spleen is likely related to phase of
scanning. It is normal in size.
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: Patient is status post Roux-en-Y gastric bypass surgery.
Enteric contrast is seen within the remnant stomach into the jejunum. There
is no contrast refluxing into the biliary limb. There is no distension of
stomach or loops of bowel. The jejunojejunostomy in the left upper quadrant
is unremarkable. Remaining small bowel loops demonstrate normal caliber, wall
thickness, and enhancement. The colon is unremarkable. The appendix is not
clearly identified but there are no secondary signs of appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: An IUD is seen within the uterus. Bilateral adnexa are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post Roux-en-Y gastric bypass surgery without evidence of internal
hernia or obstruction. No acute process within the abdomen or pelvis.
2. Large fecal loading through the colon and rectum.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Epigastric pain
temperature: 98.1
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 90.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the bariatric service and evaluated
for abdominal pain. On ___ - US Liver and GB Impression:
Normal appearance of the gallbladder and pancreas. No
intrahepatic biliary dilation. Normal common bile duct.On ___
- CT Abdomen & Pelvis Impression: No evidence of obstruction.
No free air. Previously
ingested oral contrast has move distally into the colon.
Contrast within the excluded stomach as seen on prior CT may
represent gastro gastric fistula versus reflux of
contrast.ENDOSCOPIC STUDIES:EGD:Irregular z-line at the GE
junction. (biopsy)Previous Roux-n-Y bypass surgery of the
stomach (biopsy)Raised nodule with central umbilication with
overlying mucous seen in the fundus. This was concerning for a
fistula.Both blind and Roux limbs of the jejunum were examined.
Normal
mucosa was seen.Otherwise normal EGD to jejunum.
Although imaging did not reveal a clear cause for the patients
pain, per GI fellow Dr. ___ was started on BID PPI. She was
given carafate as well which she reported improved her symptoms.
Her diet was advanced as tolerated.She continued to have
symptoms of pain after eating and the CT scan was repeated on
___. This scan showed large amound of fecal loading throughout
the colon and rectum. Therefore, she was given a more aggressive
bowel regimen.
Upon discharge, pt is alert and oriented ambulating
independently without difficulty. She is cardiovascularly
stable. Her breath sounds are clear and her breathing is
non-labored. Reports abdominal pain is improved and is
tolerating stage V Bariatric diet with minimal discomfort, no
nausea, no emesis. Minimal tenderness to palpation in upper
gastric area. Biopsy results from EGD pending. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lovenox
Attending: ___
___ Complaint:
fever, palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with NSCLC with bony mets s/p XRT finished ___ now on
taxotere (C2 ___, who presents with palpitations and fever.
For the past week, the patient has felt fatigued. For the past
several days, he has had a cough productive of clear sputum. On
___ the patient was seen by his cardiologist Dr. ___
noted HR to 160s and sent the patient to the ED, where he was
diagnosed with new onset paroxysmal A-fib. He was also noted to
be neutropenic but discharged home since not febrile. Overnight,
he had multiple episodes of palpitations and this morning he
felt warm and sweaty, and found his temp to be 100.7 so he came
back to the ED. He has a positive sick contact (his ___ year old
daughter has a cough and recently received antibiotics from her
pediatrician for presumed pneumonia). No GI or GU symptoms at
this time.
In the ED the patient's initial vitals signs were: 98.6 116
___ 98% RA. Labs were significant for WBC 1.7 (46% PMN,
ANC 782), H/H 9.9/31.4, plt 243, Na 135, K 4.2, Cl 101, HCO3 22,
BUN 17, Cr 0.9, glucose 92, troponin <0.01, and lactate 1.8. UA
with no significant abnormalities. CXR w/ possible PNA. The
patient was given vancomycin and cefepime. He was transferred to
OMED for further management.
On the floor, VS: 99.9 124/80 115 16 100% RA. Hemodynamically
stable, no respiratory distress, feels generally well except
tired and with cough. No palpitations at this point.
Review of Systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
blurry vision, diplopia, loss of vision, photophobia. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain or tightness, lower extremity edema. Denies shortness
of breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: patient complained of clavicular pain
___: MRI of the clavicle w/ abnormal bone marrow uptake
___: MRI of the clavicle w/ abnormal bone marrow uptake
___: CT chest which showed a spiculated LLL 15x26 mm
lesion, as well as a likely liver cyst
___: PET scan showed an FDG avid LL mass, hilar and
mediastinal adenopathy as well as uptake in the right clavicle
and right sacrum
___: Bx/EBUS, bx showed malignant cells c/w adenocarcinoma
___: ___ MRI negative for metastatic disease
___: radiation to right clavicle
___: mild hemoptysis prior to starting chemo
___: C1 Cis+Alimta with 25% ___ ___ to expected tolerance
___: Radiation to lung started due to hemoptysis,
total 14 treatments.
___: C2 Cis+Alimta full dose with Zometa
___: C3 Cis+Alimta full dose
___: B12
___: C4 Cis+Alimta full dose with Zometa
___: Maintenance Alimta
___: CTA sit diagnosed PE and T4 and T9 bone lesion
progression, patient did not tolerate Lovenox, Fragmin and
Coumadin due to ___ joint pain, started on Xarelto
___: 10 fractions of XRT to T8-10 at ___
___: C1 Taxotere, Alimta d/c'd
___: schedule for C2 taxotere
PAST MEDICAL HISTORY:
___ c/b bone metastasis (EGFR negative, ALK negative, KRAS
positive)
COPD/asthma
Colonic adenoma
Gallstones
Diverticulosis
BPH (benign prostatic hyperplasia)
Acute MI s/p DES in ___
Pulmonary embolism
Hyperlipidemia
Social History:
___
Family History:
Father: CAD/PVD
Maternal Grandmother: ___ - Type II
Mother: Cancer
Physical ___:
ADMISSION EXAM:
----------------
VITALS: 99.9 124/80 115 16 100% RA
General: Alert, oriented, NAD, looks very well
HEENT: Mucous membranes moist, sclera anicteric, EOMI
Neck: JVD at clavicle
CV: RRR, S1 S2, no MRG
Lungs: Bibasilar crackles, otherwise CTAB
Abdomen: +BS, soft, nontender, not distended
Ext: Warm well-perfused, DP 2+ b/l, no edema, cyanosis,
clubbing
Neuro: moving all extremities, fluent speech and good historian
DISCHARGE EXAM:
----------------
VITALS: 98.3 128/68 100 16 100% RA
General: Alert, oriented, NAD, looks very well
HEENT: Mucous membranes moist, sclera anicteric, EOMI
Neck: JVD at clavicle
CV: RRR, S1 S2, no MRG
Lungs: Bibasilar crackles, otherwise CTAB
Abdomen: +BS, soft, nontender, not distended
Ext: Warm well-perfused, DP 2+ b/l, no edema, cyanosis,
clubbing
Neuro: moving all extremities, fluent speech and good historian
Pertinent Results:
ADMISSION LABS:
---------------
___ 07:10AM BLOOD WBC-1.7*# RBC-3.40* Hgb-9.9* Hct-31.4*
MCV-92 MCH-29.3 MCHC-31.7 RDW-14.2 Plt ___
___ 07:10AM BLOOD Neuts-46* Bands-0 ___ Monos-10
Eos-6* Baso-0 ___ Metas-2* Myelos-2* Promyel-2* NRBC-2*
___ 07:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:10AM BLOOD Glucose-92 UreaN-17 Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-22 AnGap-16
___ 07:10AM BLOOD ALT-38 AST-37 AlkPhos-105 TotBili-0.5
___ 07:22AM BLOOD Lactate-1.8
DISCHARGE LABS:
---------------
___ 06:55AM BLOOD WBC-3.0*# RBC-3.09* Hgb-9.6* Hct-28.1*
MCV-91 MCH-30.9 MCHC-34.0 RDW-14.7 Plt ___
___ 06:55AM BLOOD Neuts-52 Bands-10* Lymphs-12* Monos-20*
Eos-0 Baso-1 Atyps-2* ___ Myelos-3*
___ 06:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Stipple-OCCASIONAL Tear Dr-OCCASIONAL
___ 06:55AM BLOOD Glucose-82 UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-27 AnGap-12
___ 06:55AM BLOOD TSH-0.74
IMAGING:
---------------
CXR
___
FINDINGS: There is a left lower lobe retrocardiac opacity, more
pronounced from ___, which is concerning for
developing pneumonia rather than atelectasis superimposed on a
pre-existing lesion as seen on the prior PET-CT. A subtle right
apical opacity is again seen and may relate to apical pleural
thickening. The lungs continue to be hyperinflated, likely
representing chronic obstructive pulmonary disease. There is no
pleural effusion or pneumothorax. The heart and mediastinal
contours are within normal limits. IMPRESSION: Increased left
lower lobe retrocardiac opacity is concerning for developing
pneumonia rather than atelectasis superimposed on a pre-existing
lesion as seen on the prior PET-CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL 3X,Q5MINUTES:PRN chest pain
8. Clopidogrel 75 mg PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN sob
or wheeze
11. Finasteride 5 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. Prochlorperazine 5 mg PO Q6H:PRN nausea
15. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL 3X,Q5MINUTES:PRN chest pain
7. Omeprazole 40 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 5 mg PO Q6H:PRN nausea
10. Rivaroxaban 20 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO HS
13. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN sob
or wheeze
14. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth once daily Disp #*5 Tablet Refills:*0
15. Multivitamins 1 TAB PO DAILY
16. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
This can be purchased over the counter.
17. Levofloxacin 750 mg PO DAILY Duration: 6 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once daily Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Fever with borderline neutropenia
Pneumonia
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSIS:
Non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Palpitations, fever. Evaluate for cardiopulmonary process.
TECHNIQUE: Frontal and lateral chest radiographs were obtained with the
patient in the upright position.
COMPARISON: Chest radiograph from ___, PET-CT from ___ and CT from ___.
FINDINGS: There is a left lower lobe retrocardiac opacity, more pronounced
from ___, which is concerning for developing pneumonia rather
than atelectasis superimposed on a pre-existing lesion as seen on the prior
PET-CT. A subtle right apical opacity is again seen and may relate to apical
pleural thickening. The lungs continue to be hyperinflated, likely
representing chronic obstructive pulmonary disease. There is no pleural
effusion or pneumothorax. The heart and mediastinal contours are within
normal limits.
IMPRESSION: Increased left lower lobe retrocardiac opacity is concerning for
developing pneumonia rather than atelectasis superimposed on a pre-existing
lesion as seen on the prior PET-CT.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
WALK IN
Chief complaint: AFIB
FEVER,PALPITATIONS
Diagnosed with ATRIAL FIBRILLATION, NEUTROPENIA, UNSPECIFIED
NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED, PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.5
98.6
heartrate: 126.0
116.0
resprate: 16.0
16.0
o2sat: 97.0
98.0
sbp: 114.0
108.0
dbp: 77.0
81.0
level of pain: 0
0
level of acuity: 1.0
3.0 | ___ with NSCLC with bony mets s/p XRT finished ___ now on
taxotere (C2 ___, ANC >1000, who now presents with
palpitations and fever.
___ with NSCLC with bony mets s/p XRT finished ___ now on
taxotere (C2 ___, with ANC ~700, who presented with
palpitations and fever.
#FEVER: At first was treated with IV Vancomycin and Cefepime for
febrile neutropenia. However, his ANC continued to trend up
during this admission and he was not neutropenic. He had a cough
and positive sick contact, with CXR possibly concerning for
pneumonia. Since he was not neutropenic, his antibiotics were
narrowed to PO levofloxacin for a 7 day course, last dose
___.
#PALPITATIONS: New diagnosis of atrial fibrillation, could be
triggered by likely acute infection and hypovolemia. TSH was
wnl.
# NEUTROPENIA: Likely secondary to chemo recently. WBC nadired
at 1.1 and uptrended to 3.0 on discharge.
# NSCLC: Mgmt per primary Oncologist.
# H/o PE: No dyspnea or indication that PE is worse. Patient
continued rivaroxaban.
# H/o MI: Continued metoprolol succinate (50mg QD), statin,
aspirin, plavix |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
aspirin / sodium bicarbonate
Attending: ___.
Chief Complaint:
Fall with headstrike
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo M hx dementia, prior CVA on Plavix who presents from
SNF after a mechanical fall. Pt slipped while using the
bathroom
on his own diarrhea. + headstrike, unknown LOC. Pt was taken
to
OSH where head CT showed small right frontal IPH and right
frontal brain mass. ___ denies HA, numbness, weakness or
tingling. Daughter and HCP ___ (living in ___
relays that the brain mass is known and followed by a provider
in
___, no surgical intervention planned given age and hx
dementia. She reports that the patient sounds to be at his
baseline MS which is oriented to self and location and typically
the month but not year or day. She confirms that the patient is
a DNR however as HCP she would agree to procedures that would
allow him to maintain his level of function. He currently
ambulates on his own, goes on frequent outings with family
members.
Past Medical History:
Thalamic stroke, DNR, CAD, HTN, HTN, hx prostate CA, right
frontal brain mass, dementia
Social History:
___
Family History:
Non-contributory
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
O: T:97.7 104 118/82 16 95%
Gen: WD/WN, comfortable, NAD.
HEENT: occipital hematoma
Neck: Supple. No midline temderness
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place with options, and Month
but not year or day.
Language: Speech fluent with good comprehension and repetition.
Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light bilaterally.
Visual fields grossly intact.
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.
Slight Left pronator drift
Strength full power ___ throughout.
Sensation: Intact to light touch bilaterally.
========================
DISCHARGE PHYSICAL EXAM
========================
Unchanged from admission.
Pertinent Results:
=====
LABS
=====
Blood cultures (___): No growth to date, final result pending
==========
IMAGING
==========
NCHCT (___):
Apparent right frontal mass, unchanged from prior study. It is
unclear if the hyperdense material represents hemorrhage or
calcification. Consider MRI for further delineation.
Medications on Admission:
Clopidogrel 75mg daily
Atorvastatin 10mg daily
Calcium carbonate
Metoprolol ER 25 mg daily
Oxybutynin chloride ER 10mg daily
Tamsulosin 0.4mg daily
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Oxybutynin 10 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R frontal ___
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: ___ s/p fall, hx of diarrhea, no abd pain; no
cough/sob/cp // CXR: eval for consolidation
TECHNIQUE: Upright PA and lateral chest
COMPARISON: None available
FINDINGS:
Lung volumes are low. Heart size is normal. The mediastinal and hilar contours
are normal. There is no pleural effusion or pneumothorax.
IMPRESSION:
Low lung volumes. No evidence of pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with right IPH status post fall. Please perform
by 8 am, follow hemorrhage .
TECHNIQUE: Contiguous multidetector CT scan through the head was performed
without intravenous contrast.
DOSE: DLP: 897.12 mGy-cm. CTDIvol: 53.90 mGy.
COMPARISON: CT from ___.
FINDINGS:
There is a right frontal mass with internal hemorrhage or calcification,
unchanged from the prior study. Apparent increase in surrounding edema may be
related to markedly different angle of scan acquisition. There is no evidence
of vascular territorial infarction. Old lacunar infarction in the
periventricular white matter on the left. There is no fracture. The imaged
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
Apparent right frontal mass, unchanged from prior study. It is unclear if the
hyperdense material represents hemorrhage or calcification. Consider MRI for
further delineation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ICH
Diagnosed with TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL
temperature: 97.7
heartrate: 104.0
resprate: 16.0
o2sat: 95.0
sbp: 118.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old man with a past medical history of
right frontal brain mass, dementia, and thalamic stroke who was
transferred to ___ ___ from an OSH following a mechanical
fall at nursing facility with ___ showing a small right
frontal hemorrhage and known right frontal brain mass. Pt was
admitted to the neurosurgery service for further monitoring.
Antiepileptics were held as there was no evidence of seizures.
Plavix was held given small hemorrhage and SBP was maintained at
<140 with plan to restart plavix in 2 weeks. Repeat NCHCT ___
was stable. Pt was feeling well on day of discharge and was
discharged back to his nursing facility. Pt should continue to
follow with ___ regarding management of the lesion or he may
follow up in the Brain Tumor Clinic here at ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / codeine /
Ocaliva
Attending: ___
Chief Complaint:
melena, weakness
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___ y/o female w/ a hx of primary biliary
cirrhosis c/b portal hypertension, ascites, grade I esophageal
varices s/p banding, portal hypertensive gastropathy, GAVE s/p
multiple APC treatments, recurrent GI bleeds, and iron
deficiency
anemia who presents with lightheadedness, DOE, and melena.
The patient reports a prolonged history of GAVE requiring
frequent blood transfusions and repeat APC. She was also
diagnosed with PBC based on liver biopsy showing stage ___
fibrosis and fibroscan in ___ c/w liver cirrhosis. An EGD on
___ showed grade I non bleeding varices, scarring in the
distal esophagus, as well as extensive nodular portal
hypertensive gastropathy s/p ligation of polypoid mass.
She was then admitted to ___ from ___ for acute on
chronic anemia secondary to upper GI bleed. At that time, she
was
transfused prn and treated w/ PPI, suclralfate, octreotide gtt,
and ceftriaxone. Repeat EGD re-demonstrated known varices and
GAVE, treated w/ APC with plan to repeat EGD in 1 month.
Following, discharge the patient felt very well until ___ days
ago when she began having progressive fatigue, which she
attributed to not receiving an iron infusion. Over this time,
she
noted recurrent melanic stools (___). No hematochezia,
abdominal pain, nausea, vomiting or diarrhea. She then developed
___ days of dyspnea on exertion, intermittent lightheadedness
with movement, and palpitations. She describes a rapid heart
beat
that can happen at rest or with movement and resolves after ~10
seconds without treatment. She has had a history of similar
symptoms, often when she is anemic. No shortness of breath at
rest, headaches, weakness, numbness/tingling, syncope, chest
pain, cough, fever, or chills.
In the ED initial VS were T 98.9, HR 98, BP 109/73, RR 18, O2
99%
on RA.
Exam notable for conjunctival pallor, tachycardic, soft,
non-tender abdomen, cold extremities, dark stool, stool guaiac
positive
Labs were revealing for:
- Hbg 9.5 (from 8.8 on last discharge)
- AST 44, ALT 24, AP 195, Tbili 0.6, Alb 2.9, lactate 1.2, trop
<0.01
Studies performed include:
- CXR: No acute cardiopulmonary abnormality
Patient was given:
- 1L NS, pantoprazole 40 mg IV, octreotide gtt, Zofran 4 mg IV,
acetaminophen 1000 mg, 2u pRBC
Consults:
GI was consulted and recommended octreotide gtt, PPI, CTX, with
admission to ET for possible EGD in the morning
Vitals on transfer: Temp 98.5F BP 107/63 HR 81 RR 16 99% on RA
Upon arrival to the floor, she reports feeling well,
specifically
with being here and after receiving 2u pRBC. She denies
lightheadedness, dizziness, abdominal pain, melena or
hematochezia. She refuses octreotide as it has caused recurrent
headaches. No leg swelling, weight changes, abdominal
distention,
or confusion.
Past Medical History:
Primary biliary cirrhosis
Hashimotos thyroiditis
GAVE
anemia
s/p cholecystectomy
s/p appendectomy
Social History:
___
Family History:
aunt with colon cancer in ___
mom with celiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp 98.0F BP 118/73 HR 76 RR 21 100% on RA
GENERAL: Elderly female in NAD. Lying comfortably in bed.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Oropharynx clear.
NECK: Supple.
CARDIAC: RRR with normal S1 and S2. II/VI systolic murmur
throughout, loudest over RUSB. No rubs or gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Normal bowels sounds. Soft, obese, non-tender,
non-distended. No guarding or masses. No fluid wave appreciated.
EXTREMITIES: Warm, well perfused. Trivial ___ edema, no erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: A&Ox3. CN2-12 intact. ___ strength and normal
sensation throughout. No asterixis.
DICHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 742)
Temp: 97.9 (Tm 98.4), BP: 92/60 (88-105/56-71), HR: 70
(70-79), RR: 18 (___), O2 sat: 98% (95-98), O2 delivery: Ra,
Wt: 134.48 lb/61.0 kg (134.48-141.75)
GENERAL: pleasant woman lying comfortably in bed.
HEENT: NCAT. EOMI. Sclera anicteric and without injection. MMM.
Oropharynx clear.
NECK: Supple.
CARDIAC: RRR with normal S1 and S2. II/VI systolic murmur
throughout, loudest over RUSB. No rubs or gallops.
LUNGS: Normal respiratory effort. CTAB.
ABDOMEN: Soft, non-tender, non-distended. No guarding or masses.
EXTREMITIES: Warm, well perfused. No ___ edema, no erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: A&Ox3. No asterixis.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:27PM BLOOD WBC-5.1 RBC-3.44* Hgb-9.5* Hct-30.3*
MCV-88 MCH-27.6 MCHC-31.4* RDW-21.5* RDWSD-68.9* Plt ___
___ 03:27PM BLOOD Neuts-72.4* Lymphs-15.7* Monos-8.0
Eos-2.7 Baso-0.8 Im ___ AbsNeut-3.70 AbsLymp-0.80*
AbsMono-0.41 AbsEos-0.14 AbsBaso-0.04
___ 03:27PM BLOOD ___ PTT-28.0 ___
___ 03:27PM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-144
K-3.9 Cl-110* HCO3-22 AnGap-___ 03:27PM BLOOD ALT-24 AST-44* AlkPhos-195* TotBili-0.6
___ 03:27PM BLOOD cTropnT-<0.01
___ 06:23AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.9
STUDIES:
========
EGD (___)
3 cords of grade I varices seen in the distal esophagus. The
varices were not bleeding. No stigmata of recent bleeding.
Multiple nonbleeding ulcers found in the antrum and body of
stomach. No active bleeding. All ulcers clean based. Consistent
with GAVE and post-APC ulcers. Erythema and congestion in the
body and fundus compatible with portal hypertensive gastropathy.
DISCHARGE LABS:
===============
___ 05:25AM BLOOD WBC-3.7* RBC-3.38* Hgb-9.4* Hct-29.7*
MCV-88 MCH-27.8 MCHC-31.6* RDW-19.8* RDWSD-63.7* Plt ___
___ 05:25AM BLOOD ___ PTT-28.8 ___
___ 05:25AM BLOOD Glucose-89 UreaN-14 Creat-0.5 Na-144
K-4.0 Cl-115* HCO3-20* AnGap-9*
___ 05:25AM BLOOD ALT-18 AST-31 LD(LDH)-171 AlkPhos-145*
TotBili-0.5
___ 05:25AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0 Iron-80
___ 05:25AM BLOOD calTIBC-325 Ferritn-56 TRF-250
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Rifaximin 550 mg PO BID
3. Sucralfate 1 gm PO QID
4. Ursodiol 900 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lactulose 15 mL PO BID
7. Pantoprazole 40 mg PO Q24H
8. Spironolactone 50 mg PO DAILY
9. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lactulose 15 mL PO BID
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Pantoprazole 40 mg PO Q24H
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Sucralfate 1 gm PO QID
9. Ursodiol 900 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Melena
GAVE
Esophageal varices, PHG
Primary Biliary Cirrhosis
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 PMH cirrhosis ___ PBC, p/w signs/sx GI bleed,.
Recent admission with SOB.// PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Heart size is normal. Mild atherosclerotic calcifications are seen in the
aortic knob. The mediastinal and hilar contours are normal. The pulmonary
vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax
is seen. There are no acute osseous abnormalities. Mild S shaped scoliosis of
the thoracolumbar spine is again seen. Clips are noted in the right upper
quadrant of the abdomen.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Dyspnea
Diagnosed with Gastrointestinal hemorrhage, unspecified, Dizziness and giddiness, Dyspnea, unspecified
temperature: 98.8
heartrate: 98.0
resprate: 18.0
o2sat: 99.0
sbp: 109.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT:
==================
___ with history of primary biliary cirrhosis c/b portal
hypertension (esophageal varices s/p banding, GAVE), iron
deficiency anemia, s/p EGD ___ and repeat ___ with grade I
varices and GAVE, who presents with lightheadedness, DOE, and
Hgb 8.8 in setting recurrent melena.
ACTIVE ISSUES:
==============
# UGIB
# Acute on chronic blood loss anemia
Patient with repeat admissions for melena in setting of known
GAVE s/p multiple APC treatments as well as ligation banding,
and esophageal varices s/p banding. Patient required 2 u pRBC
during hospital stay. Sucralfate was held. She declined
octreotide gtt despite discussion regarding benefit and risks.
She was treated with IV PPI and CTX 1 g daily until discharge.
She remained hemodynamically stable and underwent an EGD on ___
with biopsy performed and pending at discharge. Her Hgb on
discharge was 9.4. She was set up for outpatient IV iron
transfusions.
# Primary Biliary Cirrhosis (Child A/6, MELD 6)
Past history of decompensation by HE, esophageal varices and
GAVE, as well as ascites. No known history of SBP. Note that
although liver transplant candidacy usually discussed after MELD
>= 15, patient was interested in learning more about potential
transplant. Given age and frailty, patient may not be
appropriate transplant candidate at this time but will continue
this discussion with her outpatient hepatologist. Her home
lactulose and diuretics were held in setting of active upper GI
bleed on admission. She did not have any signs of hepatic
encephalopathy throughout her admission.
CHRONIC/STABLE ISSUES:
======================
# ___ thyroiditis: Continued on home levothyroxine 125 mcg
TRANSITIONAL ISSUES:
====================
[] Consider TTE given murmur
[] Follow-up with outpatient hepatologist regarding EGD in 1
month for repeat ___
[] Patient should hear about outpatient iron transfusions
starting next week for chronic blood loss anemia.
[] ___: No concerning lesions on admission US. Will need
outpatient screening q6 mo with RUQUS or other appropriate
imaging
[] HAV Ab negative. Consider vaccination.
#CODE: FULL
#CONTACT: Health care proxy chosen: No
Info. offered to patient?: Yes
Offered on date: ___
Comments: Pt wants her husband ___ ___
daughter to be her HCP. Pt advised to file HCP form with family. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, lysis of adhesions and right
inguinal hernia repair with mesh.
History of Present Illness:
MR. ___ is an affable ___ year old male vasculopath with
atrial fibrillation (taking pradaxa), CAD s/p stent placement,
and revascularization of RLE including a R fem-AK pop bypass
graft, with history of previous ventral incisional hernia
repairs who presents with abdominal pain, nausea, and emesis. He
has a known right inguinal hernia that is enlarged and
intermittently
tender. He recounts 3 day history of abdominal discomfort with
nausea and NBNB emesis. He has decreased frequency of stools but
had liquid stools earlier today. No flatus since this morning.
No blood or melena.
On evaluation in the ED, he is afebrile VSS. His heart rate is
irregular but initially rate controlled. He appears dehydrated
but in good spirits. His abdomen is rotund and firm but close to
his baseline with diffuse abdominal tenderness. He has a large
right inguinal hernia that is easily reducible at
bedside. There are no overlying skin changes. Previous midline
ventral hernias are without obvious fascial defects. His
laboratory values are reassuring with no leukocytosis (WBC 5.1k)
and a normalized lactate 2.5->1.3 after IVF resuscitation. A
CTAP w/ contrast was initially thought to suggest SBO secondary
to a RIH containing a portion of the cecum and terminal ileum.
However, due to proximally collapsed small bowel and a narrow
elongated intra-abdominal transition point well proximal to the
reducible hernia, he likely has a partial SBO from
intra-abdominal adhesions. An NGT was placed at bedside with
copious bilious and gastric output.
Past Medical History:
PMH:
High Cholesterol, HTN, afib, R femoral arterybypass , cardiac
stent, hernia, borderline diabetes
PSH:
umbilical hernia repair ___)
repair of recurrent incisional hernia with mesh ___ ___,
exploratory laparotomy/removal of infected mesh/component
separation ___ ___, recurrent laparoscopic incisional
hernia repair ___ ___
Vascular PSH:
Redo R fem-AK pop bypass w/GSV Right fem-AK-pop bypass graft
with
PTFE ___ ___,
___ ___,
angiogram/lysis of occluded graft/stenting of distal anastamosis
___ ___, angiogram/AngioJet thrombectomy of DP artery
___ ___,
angiogram/thrombolysis of occluded graft ___ ___,
angiogram/PTA of in-stent stenosis ___ ___,
diagnostic angiogram ___ ___
Social History:
___
Family History:
Mother had heart problems and father died of a cancer that
wrapped around his aorta. His brother had emphysema.
Physical Exam:
Admission Physical Exam:
VS: 98.2F 90 126/76 16 99% RA
Gen: affable, conversant older man, NAD
CV: irregular irregular, initially HR controlled
Pulm: b/l wheezing, no obvious crackles
Abd: firm abdomen, with moderate diffuse tenderness on exam, no
rebound or guarding, no peritoneal signs, old midline surgical
scar well healed without any fascial defects
right groin with reducible non-tender inguinal hernia, no
overlying skin changes
Ext: b/l ___ w/ DP pulses 2+; warm well perfused with brisk
capillary refill and neurological intact
Discharge Physical Exam:
VS: T: 98.0, BP: 138/84, HR: 96, RR: 18, O2: 96% RA
GENERAL: A+Ox3, NAD
CV: regular rate, irregular rhythm
PULM: CTA b/l
ABD: soft, distended, non-tender, no rebound or guarding.
Midline and RLQ surgical incision with staples intact, skin
well-approximated without s/s infection.
Extremities: warm, well-perfused, no edema.
Pertinent Results:
___ 07:08PM LACTATE-1.3
___ 07:00PM cTropnT-<0.01
___ 05:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-2* PH-5.5 LEUK-NEG
___ 05:10PM URINE RBC-6* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
___ 05:10PM URINE HYALINE-52*
___ 05:10PM URINE MUCOUS-FEW
___ 02:10PM K+-4.6
___ 01:17PM LACTATE-2.5*
___ 12:55PM ___ PTT-47.8* ___
___ 12:50PM GLUCOSE-143* UREA N-28* CREAT-1.2 SODIUM-135
POTASSIUM-7.1* CHLORIDE-100 TOTAL CO2-21* ANION GAP-21*
___ 12:50PM ALT(SGPT)-23 AST(SGOT)-64* ALK PHOS-82 TOT
BILI-0.5
___ 12:50PM LIPASE-26
___ 12:50PM cTropnT-<0.01
___ 12:50PM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-4.7*
MAGNESIUM-2.2
___ 12:50PM WBC-5.1# RBC-5.29 HGB-15.8# HCT-49.2# MCV-93
MCH-29.9# MCHC-32.1 RDW-16.3* RDWSD-55.4*
___ 12:50PM NEUTS-55 BANDS-8* LYMPHS-15* MONOS-21* EOS-1
BASOS-0 ___ MYELOS-0 AbsNeut-3.21 AbsLymp-0.77*
AbsMono-1.07* AbsEos-0.05 AbsBaso-0.00*
___ 12:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:50PM PLT SMR-NORMAL PLT COUNT-184
IMAGING:
___: EKG:
Atrial fibrillation with a controlled ventricular response.
Leftward axis.
Right bundle-branch block. Other T wave abnormalities. Compared
to the
previous tracing of ___ the rate is now slower. Precordial
voltage
somewhat less prominent. Otherwise, unchanged.
___: CXR:
A nasogastric tube is coiled within the mid esophagus. The
heart size is
normal. The hilar and mediastinal contours are within normal
limits. There is no lobar consolidation, pneumothorax, or
pleural effusion.
___: CT ABD/PELVIS:
Right inguinal hernia containing a loop of ileum, with upstream
small bowel
obstruction. Distally decompressed bowel. No pneumatosis, fluid
collection, or free air.
___: PORTABLE PICC:
Since a recent radiograph from earlier today, a right PICC has
been
repositioned, now terminating in the region of the cavoatrial
junction. No
other relevant change.
___: ART DUP EXT LO UNI;F/U
Patent right lower extremity arteries and femoral-popliteal
bypass graft
without evidence of stenosis.
___: ART EXT (REST ONLY):
1. Right distal tibial disease with resting ABI 1.02.
2. No evidence of arterial insufficiency in the left lower
extremity with
resting ABI 1.13.
___: Portable Abdomen:
1. No evidence of ileus or obstruction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 150 mg PO BID
2. Digoxin 0.125 mg PO DAILY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Metoprolol Tartrate 100 mg PO BID
6. Rosuvastatin Calcium 40 mg PO QPM
7. Sildenafil 100 mg PO ASDIR
8. TraZODone 50 mg PO QHS
9. Aspirin 325 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Docusate Sodium 100 mg PO QHS
12. Senna 8.6 mg PO QHS
13. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
2. Digoxin 0.125 mg PO DAILY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Tartrate 100 mg PO BID
6. Senna 8.6 mg PO BID:PRN constipation
7. Acetaminophen 1000 mg PO Q6H:PRN pain
8. Aspirin 325 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Rosuvastatin Calcium 40 mg PO QPM
12. Sildenafil 100 mg PO ASDIR
13. Vitamin E 400 UNIT PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. TraZODone 50-100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction and right inguinal hernia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with severe diffuse abdominal pain, nausea and vomiting for 3
daysNO_PO contrast // Evaluate for enteritis, colitis, appendicitis, abscess
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 910 mGy-cm.
COMPARISON: CT abdomen ___, CT chest ___
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis bilaterally. There is no
evidence of pleural or pericardial effusion. Mitral annular calcification is
similar to ___. A 2 mm right base pulmonary nodule is unchanged
from ___.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of suspicious renal lesions or hydronephrosis. Simple
cyst in the lateral left upper pole measures up to 2.8 cm, smaller compared to
___. Simple cyst in the medial left upper pole measures up to
2.6 cm, similar to ___. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is distended. There are dilated, fluid-filled
proximal small bowel loops with air-fluid levels beginning at the proximal
jejunum. In the left lower quadrant, there is a loop of small bowel which
gradually narrows with some fecalized small bowel contents in a loop in the
lower abdomen (601:33). Distal to this, loops of small bowel are entirely
collapsed, leading to a right inguinal hernia which contains a portion of the
terminal ileum as well as a portion of the cecum. There is a small amount of
free fluid in the hernia sac. Small bowel loops demonstrate normal wall
thickness and enhancement. The colon and rectum are predominantly collapsed.
Diverticulosis of the transverse, descending, and sigmoid colon is worst in
the sigmoid, without evidence of wall thickening or fat stranding. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Ventral hernia repair mesh is again seen.
IMPRESSION:
1. Small-bowel obstruction without a discrete transition point, but with a
long zone of gradual narrowing in the left lower quadrant with distally
decompressed small bowel. This distally decompressed small bowel eventually
leads into a right inguinal hernia containing cecum and terminal ileum with
adjacent free fluid.
2. No fluid collection.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man with small bowel obstruction. Evaluate NG tube
placement.
TECHNIQUE: Portable upright AP radiograph view of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The tip of the NG tube projects over the midline, in the distal esophagus.
The heart size is mild-to-moderately enlarged. Central pulmonary vascular
congestion is minimal. Mild left basilar atelectasis. No frank pulmonary
edema, pleural effusion, or pneumothorax.
IMPRESSION:
1. NG tube probably in distal esophagus.
2. Cardiomegaly and central pulmonary congestion.
RECOMMENDATION(S): Advance NG-tube at least 10-15 cm to the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man SBO s/p NGT placement // eval for NGT position
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 3 hours earlier.
IMPRESSION:
NG tube tip isin the stomach. No other interval change from prior study.
Radiology Report
INDICATION: SBO.
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Radiographs from ___.
IMPRESSION:
A nasogastric tube is coiled within the mid esophagus. The heart size is
normal. The hilar and mediastinal contours are within normal limits. There
is no lobar consolidation, pneumothorax, or pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:21 ___, 12 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ y/o M HD5 w/ SBO, symptoms improving on ___, now w/
decreased bowel function, nausea, NGT reinsertion. Interval change- please use
oral and 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) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP =
10.8 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.4 cm; CTDIvol = 17.0 mGy (Body) DLP = 888.8
mGy-cm.
Total DLP (Body) = 900 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Again seen are two simple cysts arising from the right kidney, measuring 2.5
cm and 2.8 cm. There is no evidence of suspicious focal renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: An enteric tube terminates in the stomach. Again seen are
multiple dilated loops of small bowel, with a transition point now located in
a right inguinal hernia, which also contains a small amount of fluid and a
loop of the ileum (601b: ___ 2:86). The cecum was previously included
within the hernia on the ___ examination, but is not currently
involved. There is a downstream loop of nondistended bowel containing fluid,
with more distal complete collapse of the small bowel. There is no
pneumatosis or abnormal wall enhancement. There is no free air.
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 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. Moderate atherosclerotic
disease is noted.
BONES: There is an old spinous process fracture at the level of L3 (2:43).
There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a right inguinal hernia containing small bowel with a
transition point, and a small amount of free fluid (2:86). There is mesh in
the anterior abdominal related to prior ventral hernia repair.
IMPRESSION:
Right inguinal hernia containing a loop of ileum, with upstream small bowel
obstruction. Distally decompressed bowel. No pneumatosis, fluid collection,
or free air.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 2:42 ___, 20 minutes after discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line // new right PICC 53 cm ___
___ Contact name: ___: ___ new right PICC 53 cm ___
___
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS ___ THROUGH ___.
NEW RIGHT PIC LINE EXTENDS INTO THE LEFT SUBCLAVIAN VEIN, NO LESS THAN 8 CM
BEYOND THE ORIGIN OF THE SVC. ESOPHAGEAL DRAINAGE TUBE PASSES INTO THE DISTAL
STOMACH.
MODERATE CARDIOMEGALY IS MORE PRONOUNCED. RIGHT LUNG IS CLEAR ALTHOUGH THE
PULMONARY VASCULATURE IS ENGORGED. HETEROGENEOUS OPACIFICATION LATERAL TO THE
LEFT HILUS COULD BE EARLY PNEUMONIA. NO PLEURAL ABNORMALITY.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with PICC // Pt had a picc pulled backed 3cm
needs repeat ___ ___ Contact name: ___: ___
IMPRESSION:
Since a recent radiograph from earlier today, a right PICC has been
repositioned, now terminating in the region of the cavoatrial junction. No
other relevant change.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT
INDICATION: ___ year old man s/p redo RLE bypass ___ // s/p RLE redo BPG;
eval patency
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound images were
obtained of the right lower extremity arteries and graft.
COMPARISON: ___.
FINDINGS:
The right common femoral artery is patent with triphasic waveforms and a peak
systolic velocity of 99 cm/s.
The right femoral popliteal graft is patent with triphasic waveforms
throughout and peak systolic velocity is as follows:
Proximal anastomosis: 53 cm/s
Proximal thigh: 121 cm/s
Mid thigh: 95 cm/s
Distal thigh: 100 cm/s
Distal graft: 85 cm/s
Distal anastomosis: 90 cm/s
The popliteal artery is patent with multiphasic waveforms and a peak systolic
velocity of 49 cm/s.
IMPRESSION:
Patent right lower extremity arteries and femoral-popliteal bypass graft
without evidence of stenosis.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man s/p redo RLE bypass ___ // s/p redo BPG, eval
patency
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: None
FINDINGS:
On the right side, monophasic waveforms are seen in the posterior tibial and
dorsalis pedis arteries. The right ABI was 1.02.
On the left side, triphasic Doppler waveforms are seen in the posterior tibial
and dorsalis pedis arteries. The left ABI was 1.13.
Pulse volume recordings showed dampened amplitudes at the level of the right
ankle and metatarsals as compared the left.
IMPRESSION:
1. Right distal tibial disease with resting ABI 1.02.
2. No evidence of arterial insufficiency in the left lower extremity with
resting ABI 1.13.
Radiology Report
INDICATION: ___ y/o M ___ s/p exlap, LOA, R inguinal hernia repair, now w/
abd distention // eval for ileus, dilated loops of bowel
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum. A 1.0 cm calcific density projecting over the right upper
quadrant is likely contrast containing diverticulum seen on prior CT abdomen
and pelvis from ___.
Osseous structures are unremarkable.
Postsurgical clips are noted along the mid abdomen. Mesh along the anterior
abdominal wall is related to prior ventral hernia repair.
IMPRESSION:
1. No evidence of ileus or obstruction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: n/v/d, Abd pain
Diagnosed with Unil inguinal hernia, w obst, w/o gangr, not spcf as recur
temperature: 96.7
heartrate: 79.0
resprate: 20.0
o2sat: 98.0
sbp: 143.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year-old male with history of previous
ventral incisional hernia who presented to ___ on ___
with abdominal pain, nausea, and emesis. He had history of a
right inguinal hernia was enlarged and tender on admission and
he reported a decrease in frequency of stools and flatus. CT
abdomen/pelvis revealed a small-bowel obstruction without a
discrete transition point and he was admitted to the Acute Care
Surgery service for further medical care.
The patient was initially managed conservatively and had a
nasogastric tube placed, was made NPO with IVF. The patient did
not have return of bowel function with conservative management.
On ___, the patient was consented for the OR and underwent
exploratory laparotomy, lysis of adhesions and right inguinal
hernia repair with mesh. The patient tolerated this procedure
well and had a nasogastric tube placed for bowel decompression
(reader, please refer to operative note for details). The
patient remained hemodynamically stable in the PACU and was
transferred to the surgical floor.
Once the patient passed flatus, the patient's NGT was clamped
and did not demonstrate significant residual when placed back to
suction. The NGT was removed and the patient's diet was
gradually advanced. The patient was alert and oriented
throughout hospitalization; pain was initially managed with IV
pain medication and then transitioned to oral oxycodone and
acetaminophen once tolerating a diet. The patient remained
stable from a cardiovascular standpoint; vital signs were
routinely monitored. The patient remained stable from a
pulmonary standpoint. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
Patient's intake and output were closely monitored. The
patient's foley catheter was removed and the patient voided
without issue. The patient's fever curves were closely watched
for signs of infection, of which there were none. The patient's
blood counts were closely watched for signs of bleeding, of
which there were none. The patient's home Pradaxa was held as an
inpatient due to risk of bleeding with surgery and the patient
received subcutaneous heparin. ___ 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. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gluten / seasonal allergy
Attending: ___.
Chief Complaint:
Petechiae, easy bruising, night sweats, headaches
Major Surgical or Invasive Procedure:
bone marrow biopsy, left subclavian central venous line
History of Present Illness:
___ with history of Stage I breast cancer s/p XRT completed
___, HTN who presents from ___'s office with leukocytosis of
382. Several months ago, pt began to notice some left-sided
abdominal pain. No changes in bowel habits and no issues with
nausea/vomiting. Over the past few weeks, has noticed worsening
fatigue and DOE, as well as a headache, bruising, and drenching
night sweats. In the past few days, DOE and fatigue has become
very limiting. She has also noticed a blurry spot in her vision.
Went to PCP morning prior to admission for these issues, had
blood work done that was remarkable for leukocytosis to 382, and
was sent to the ED for further work-up.
Seen by ___ in the ED, who recommended q6hr monitoring of tumor
lysis labs and DIC labs. Bone marrow biopsy was done, revealing
concentrated blasts.
In the ED, initial vitals: T 98.8, BP 125/64, HR 89, RR 16,
SpO2 96/RA
- Exam notable for:
- Labs were notable for: WBC 395.2, H/H ___, plt 27, uric
acid 8.5, LDH 1341, fibrinogen 242, INR 1.2, Cr 1.0
- Imaging: none
- Patient was given: 2L NS, 10mg IV metoclopramide, 300mg PO
allopurinol, 1g PO acetaminophen, 1g hydroxyurea
- Consults: ___
On arrival to the MICU, pt is stable and reports that her
headache and blurry vision has subsided. Vitally stable.
Review of systems:
As per HPI
Past Medical History:
breast cancer - R invasive carcinoma with tubular features, s/p
partial mastectomy, sentinel node biopsy and radiation
atypical Celiac's disease
hypertension
anxiety
arthritis
cervical spondylosis with myelopathy
Social History:
___
Family History:
father with 'heart disease', died ___ of possible CHF,
grandfather died MI early ___ no history of early MI, CHF,
arrhythmia.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 98.2, BP 97/75, HR 73, RR 20, SpO2 96/RA
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, good dentition
NECK: 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, mild TTP in LLQ, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in major muscle groups,
sensation is grossly intact
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.8 PO 100 / 60 73 18 98 RA
24Hr I/O: 2036/650 wt: 183.29 (wt 7 days ago: 182.3 lb)
Gen: Pleasant, calm female in NAD, lying in bed wearing hat
HEENT: No conjunctival pallor. No icterus. MMM. OP clear without
thrush.
NECK: JVP flat. Normal carotid upstroke without bruits.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: Small ecchymosis on L dorsal forearm, R elbow, all stable.
Otherwise no rashes/lesions.
NEURO: CN II-XII intact. A&Ox3.
LINES: Left Hickman, c/d/I mild oozing of blood, no tenderness
to palpation.
Pertinent Results:
ADMISSION LABS
==============
___ 02:30PM WBC-382.0*# RBC-2.66*# HGB-7.7*# HCT-26.2*#
MCV-99*# MCH-28.9 MCHC-29.4*# RDW-21.2* RDWSD-56.2*
___ 02:30PM NEUTS-0* BANDS-3 LYMPHS-2* MONOS-0 EOS-1
BASOS-0 ___ METAS-1* MYELOS-0 BLASTS-93* OTHER-0
AbsNeut-11.46* AbsLymp-7.64* AbsMono-0.00* AbsEos-3.82*
AbsBaso-0.00*
___ 02:30PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+
POLYCHROM-NORMAL
___ 02:30PM UREA N-17 CREAT-0.9 SODIUM-140 POTASSIUM-3.7
CHLORIDE-99 TOTAL CO2-29 ANION GAP-16
___ 02:30PM ALT(SGPT)-26 AST(SGOT)-39 ALK PHOS-87
___ 02:30PM CALCIUM-9.4
___ 02:30PM TSH-1.1
___ 02:30PM GLUCOSE-104*
___ 09:53PM RET AUT-1.7
___ 09:53PM QUAN G6PD-17.6*
___ 09:53PM ___ 09:53PM ___ PTT-27.5 ___
PERTINENT LABS/MICROBIOLOGY/PATHOLOGY
=====================================
___ 01:00AM BLOOD Fibrino-69*#
___ 09:53PM BLOOD QG6PD-17.6*
___ 09:53PM BLOOD Ret Aut-1.7
___ 09:53PM BLOOD ALT-26 AST-44* LD(LDH)-1341* CK(CPK)-59
AlkPhos-83 TotBili-0.5
___ 12:40AM BLOOD ___
___ 09:00PM BLOOD TSH-0.52
___ BONE MARROW BIOPSY: hypercellular bone marrow with
extensive involvement by B lymphoblastic leukemia
___ BONE IMMUNOPHENOTYPING: CD34+ blasts comprise 97% of
total analyzed events. Cell marker analysis demonstrates that
the majority (97%) of the cells isolated from this peripheral
blood/bone marrow are in the CD45-dim/low side-scatter "blast"
region. They express CD38, immature antigens CD34, ___, nTdT
(subset), and lymphoid associated antigens CD19, cCD79a (small
subset). They lack B and T cell associated antigens, are CD10
(cALLa) negative, and are negative for CD13, CD33, CD14, CD64,
CD117, cMPO, cCD3, cCD22, and CD15. The CD19+ blasts are
negative by cKappa and cLambda.
___ CYTOGENETIC DIAGNOSIS:
46,XX,t(4;11)(q21;q23)[9]/46,XX[9], FISH negative for BCR/ABL,
positive for MLL rearrangement, negative high grade lymphoma
panel
DISCHARGE LABS
==============
___ 12:00AM BLOOD WBC-1.2* RBC-2.44* Hgb-7.2* Hct-21.3*
MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 RDWSD-43.4 Plt ___
___ 12:00AM BLOOD Neuts-45 Bands-3 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-0.58* AbsLymp-0.54*
AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 12:00AM BLOOD ___ PTT-24.8* ___
___ 12:00AM BLOOD Glucose-118* UreaN-14 Creat-0.6 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-70* AST-28 LD(LDH)-230 AlkPhos-75
TotBili-0.4
___ 12:00AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.7* Mg-2.2
IMAGING
=======
TTE ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/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. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
findings are similar.
CT HEAD WITHOUT CONTRAST ___
No acute intracranial abnormalities.
CHEST PA/LAT ___
Low lung volumes with suspected atelectasis in the left lung
base.
MRI HEAD ___
No evidence of hemorrhage, edema, mass, mass effect, or acute
infarction.
U/S RIGHT FOOT ___
1.9 x 1.5 cm cystic structure corresponding to the palpable
abnormality is most consistent with a ganglion.
TUNNELED CENTRAL LINE ___:
Successful placement of a triple-lumen tunneled line via the
left internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL,
DAILY:PRN
5. Cetirizine 10 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Docusate Sodium 100 mg PO Frequency is Unknown
8. Senna 8.6 mg PO BID:PRN constipation
9. flaxseed oil 1,000 mg oral unknown
10. lutein 6 mg oral unknown
11. lysine 1,000 mg oral unknown
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1
capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0
2. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. melatonin 4 mg oral QHS
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea Duration: 5 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
6. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 125 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
8. Zolpidem Tartrate 5 mg PO QHS
RX *zolpidem 5 mg ` tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
10. Cetirizine 10 mg PO DAILY
11. DULoxetine 60 mg PO DAILY
12. flaxseed oil 1,000 mg oral unknown
13. lutein 6 mg oral unknown
14. lysine 1,000 mg oral unknown
15. mometasone 50 mcg/actuation nasal 2 SPRAYS EACH NOSTRIL,
DAILY:PRN
16. Nadolol 20 mg PO DAILY
17. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*10
Tablet Refills:*0
18. Vitamin D 1000 UNIT PO DAILY
19. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until told to by
your primary care doctor or oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Acute lymphocytic leukemia
SECONDARY:
Pancytopenia
Headache
Transaminitis
Obstructive sleep apnea
Ganglion cyst
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: ___ year old woman with new diagnosis acute leukemia // eval for
e/o ischemia.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
Total DLP (Head) = 940 mGy-cm.
COMPARISON: None provided.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema or mass. Basal cisterns
are patent and there is preservation of gray-white matter differentiation.
There is no shift of normally midline structures. Ventricles and sulci are
normal in overall size and configuration.
No osseous abnormalities identified. Minimal mucosal thickening of the
bilateral sphenoid sinuses. Otherwise, the remaining visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear. Visualized
portions of the orbits are unremarkable. Atherosclerotic calcification of the
cavernosal carotid arteries is noted.
IMPRESSION:
No acute intracranial abnormalities. Please note that MRI is more sensitive
in the detection of acute infarction.
Radiology Report
INDICATION: ___ with history of breast cancer, HTN who presents with
significant leukocytosis in the setting of night sweats, weight loss, easy
bruising with high concern for new acute leukemia. // r/o mediastinal mass,
other acute cardiopulmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The heart size is normal. The hila are normal. Low lung volumes. Linear
opacification the left lung base most likely represents atelectasis. No lobar
consolidation. No pleural effusion. Surgical clips in situ in the right
breast and right chest wall.
IMPRESSION:
Low lung volumes with suspected atelectasis in the left lung base.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with acute leukemia, new left subclavian line
// left subclavian CVL placement Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___ 11:50
FINDINGS:
Left subclavian central line tip in the low SVC. No pneumothorax. Stable
left basilar opacity, likely atelectasis. Surgical clips right breast. Normal
heart size, pulmonary vascularity. Postoperative changes, hardware in place
in the partially visualized cervical spine.
IMPRESSION:
New central line, no pneumothorax.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ with history of Stage I breast cancer s/p XRT presenting with
ALL, now with RUE paresthesia, evaluate for any evidence of CNS disease
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: None.
FINDINGS:
There is no evidence of hemorrhage, edema, mass, mass effect, or acute
infarction. A punctate focus of FLAIR signal hyperintensity in the left
centrum semiovale is nonspecific (07:16). The ventricles and cisterns are
age-appropriate. Principal intracranial vascular flow voids are preserved and
arteries of the circle ___ and ___ venous sinuses enhance appropriately.
Fetal origin of the right posterior cerebral artery is noted. There is no
abnormal parenchymal or meningeal enhancement.
IMPRESSION:
No evidence of hemorrhage, edema, mass, mass effect, or acute infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) IN O.R.
INDICATION: ___ year old woman with newly diagnosed ALL. Receiving consistent
fluids for prevention of tumor lysis. // Please eval for pulmonary edema.
Please eval for pulmonary edema.
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Left subclavian line ends in the low SVC. No pneumothorax pleural effusion or
mediastinal widening. Lungs lung volume but clear of any focal abnormality
aside from left basal atelectasis. Normal cardiomediastinal and hilar
silhouettes.
Radiology Report
EXAMINATION: US MSK FOOT/TOE RIGHT
INDICATION: ___ woman with new ALL with cystic lesion on the dorsum
right foot.
TECHNIQUE: Targeted grayscale and color Doppler images of the dorsum of the
right foot.
COMPARISON: None.
FINDINGS:
A targeted ultrasound in the region of palpable abnormality in the dorsum of
the right foot between the first and second digit demonstrates a 1.9 x 1.4 x
1.5 cm anechoic structure, with minimal internal debris and posterior through
transmission. There is no associated vascularity.
IMPRESSION:
1.9 x 1.5 cm cystic structure corresponding to the palpable abnormality is
most consistent with a ganglion.
RECOMMENDATION(S): Imaging follow-up can depend on patient's clinical
symptoms.
Radiology Report
INDICATION: ___ year old woman with ALL possible HSCT, needs ___
___ // please place triple lumen power tunneled access line ___
aware
COMPARISON: ___.
TECHNIQUE: OPERATORS: Dr. ___ resident 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
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 30 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.
Fluoro time: 0.1 min, dose: 2 mgy
PROCEDURE:
1. Tunneled non-dialysis line placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The access site was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A triple-lumen catheter was selected. The catheter was
tunneled from the entry site towards the venotomy site from where it was
brought out using a tunneling device. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the catheter was threaded
into the right side of the heart with the tip in the right atrium. The sheath
was then peeled away. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium. The
catheter was flushed and each lumen was capped. The catheter was sutured in
place with 0 silk sutures. Dermabond and Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied. Sterile dressings were
applied. The patient tolerated the procedure well.
The patient's prior temporary left IJ tunneled line was removed at the end of
the procedure.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing left
internal jugular vein approach triple-lumen tunneled catheter with tip
terminating in the right atrium.
IMPRESSION:
Successful placement of a triple-lumen tunneled line via the left internal
jugular venous approach. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Dyspnea, Elevated wbc
Diagnosed with Leukemia, unspecified not having achieved remission
temperature: nan
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 130.0
dbp: 75.0
level of pain: 6
level of acuity: 2.0 | ___ with history of breast cancer, HTN who presents with
significant leukocytosis in the setting of night sweats, weight
loss, easy bruising with blasts in periphery and bone marrow
consistent with acute leukemia.
#ACUTE LEUKEMIA: Leukocytosis to 395 on admission. Seen by ___
in ED and continued to follow while in the ICU. Bone marrow
biopsy shows high blast count, no Auer rods. She was started on
allopurinol and hydroxyurea in ED. Initial labs not concerning
for tumor lysis syndrome or DIC and were trended every 6 hours
through her ICU course. She was started on fluid resuscitation
with urine output maintained at over 100cc/hr. Head CT and CXR
were performed that showed no acute processes. Ophthalmology
consult performed and found retinal hemorrhage on the L which
corresponds to her area of endorsed blind spot. Bone marrow
biopsy x 2 was performed. FISH, flow cytometry, cytogeneics,
rapid heme panel were performed and were significant for Ph
negative pre-B ALL. She was given one dose of rasburicase,
started on prednisone, and hydrea. During ICU course WBC count
down from 385K to 115K without signs of tumor lysis in ICU. She
was given prophylaxis with acyclovir, PPI, and allopurinol.
She was subsequently transferred to the floor under the ___
service. She was enrolled in ___ clinical trial ___, which
entails: Cytarabine (IT day 1); Daunorubicin (days 1, 8, 15,
22); Vincristine (days 1, 8, 15, 22); Dexamethasone (days ___
Methotrexate (IT day 14). TTE was obtained prior to chemo and
showed LVEF 70%. She began chemotherapy on ___ and tolerated
it well. She was continued on IVF to target UOP of 100cc/hr.
Allopurinol was continued for TLS prevention (days ___, per
protocol). She was diuresed as needed for volume overload. She
refused transfusion as necessary to treat her anemia and
thrombocytopenia. Ciprofloxacin and Fluconazole were also
started for prophylaxis.
#ALL: Ph- pre-B ALL, with MLL. Patient is D25 of induction
chemotherapy as per protocol. She has been enrolled in trial
___, which entails: Cytarabine (IT day 1); Daunorubicin (days
1, 8, 15, 22); Vincristine (days 1, 8, 15, 22); Dexamethasone
(days ___ Methotrexate (IT day 14). TTE ___ with EF
70%. Notably, she did not receive Peg-asparaginase as she is
>___. Bone marrow biopsy was done prior to discharge, results are
pending and will be followed by Dr. ___. Given ANC > 500
will Ciprofloxacin and Fluconazole were discontinued.
#NAUSEA: will discharge with zofran ODT 4 mg, ativan 0.5mg PO as
needed for nausea.
CHRONIC ISSUES
==========================
#TRANSAMINITIS. Labs notable for ALT 50-70 chronically otherwise
WNL. Possibly due to Ciprofloxacin, Fluconazole. Also possible
effect of chemotherapy. Will continue to monitor.
#INSOMNIA. Pt currently taking home Melatonin, but reports
ongoing insomnia despite receiving this as well as Trazodone.
She was also given Diphenhydramine ___ qhs PRN. Finally
relief was achieved with ambien.
#HYPERTENSION: on nadolol and hydrochlorothiazide at home. SBPs
90-110s on arrival to ___. Held nadolol and HCTZ.
#HEADACHE. Patient reported headache intermittently. She was
given Fioricet for symptomatic relief. Opiates were avoided.
#RIGHT FOOT NODULE. Previously noted to have nodule on dorsal R
foot, believed to be consistent with ganglion cyst. No
discomfort, pain, itching from this. U/s obtained ___ and was
consistent with ganglion.
#OXYGEN REQUIREMENT. Pt reports a history of OSA, but does not
use CPAP at home. Respiratory therapy consulted ___ and
offered CPAP, but pt declined. She used nasal cannula oxygen
overnight.
#HISTORY OF VESTIBULITIS. Unclear nature of her
vestibulitis/ataxia, but per report, she may have been diagnosed
by her previous oncologist, Dr. ___, with atypical celiac
disease, with neurological manifestations. So far no
documentation has been found regarding this. Symptoms resolved
without intervention (per patient). We spoke to Dr. ___
___ ___ they stated she has never been seen by him (had a
new patient appt on ___.
#DEPRESSION. Well controlled on Cymbalta. Continued home
Cymbalta.
TRANSITIONAL ISSUES
====================================
[ ] follow-up with line care training at home
[ ] follow-up appointment on ___ with Dr. ___ for
ongoing ALL management |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
left distal tibia, proximal fibula fracture
Major Surgical or Invasive Procedure:
Left distal tibia fracture and fibula fracture reduction and
fixation ___
History of Present Illness:
___ man with history of HTN, CKD, hypothyroidism, GERD,
borderline DM who presented after a fall in the bathroom at 3am
today, sustaining a spiral distal tibia and proximal fibula
fracture. Mr. ___ described he reached out to hold a towel
bar which broke and gave way, leading to the fall. He had been
feeling fine prior to this, although is using a walker for left
hip pain, with a possible planned hip replacement. He denies
having had dizziness, lightheadedness, CP, SOB prior to the
episode. There was no LOC or head strike. He was not able to
weight bear, and crawled out of the bathroom. He was brought to
an OSH ED, found to have fractures above, and transferred here
for surgical evaluation. Underwent ORIF today which was
uncomplicated. Per the anesthesia report, he was given 1L LR,
EBL was 100ml, MAPs ___ throughout.
Past Medical History:
-HTN
-CKD (unknown baseline creatinine but follows with renal per pt)
-Hypothyroidism
-GERD
-depression
-anxiety
-neuropathy (unclear etiology)
-s/p small bowel resection and 'stomach surgery' at ___
___ in ___ (patient cannot recall why he had this surgery)
-s/p right hip replacement, right knee replacement, right
shoulder replacement
Social History:
___
Family History:
Father died from unknown cancer at ___. Mother died at ___ from
heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
In general, the patient is a well appearing ___ lying in
stretcher
Vitals: T 97.3dF HR 44 BP 152/52 RR 16 SpO2 96% RA
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh, slight discomfort with palpation at the
distal tibia
Range of motion testing deferred due to pain
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.3 170/61 86 18 93% on RA
Orthostatics:
Laying 107/42 52
Sitting 101/49 103 (unclear if this heart rate is truely
accurate)
Standing 97/44 62
General: no acute distress
HEENT: NCAT
CV: normal rate, regular rhythm, ___ systolic murmur
Lungs: crackles heard at lung bases bilaterally, otherwise clear
Abdomen: normoactive bowel sounds, soft, nontender, nondistended
Ext: LLE in cast/ACE wrap
Pertinent Results:
ADMISSION LABS
===============
___ 07:53AM BLOOD WBC-12.6* RBC-3.02* Hgb-9.7* Hct-29.5*
MCV-98 MCH-32.3* MCHC-33.0 RDW-17.6* Plt ___
___ 07:53AM BLOOD Neuts-70.5* ___ Monos-6.9 Eos-2.0
Baso-0.6
___ 07:53AM BLOOD ___ PTT-30.4 ___
___ 07:53AM BLOOD Glucose-131* UreaN-40* Creat-2.4* Na-142
K-5.0 Cl-98 HCO3-36* AnGap-13
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-13.4* RBC-2.72* Hgb-8.7* Hct-26.3*
MCV-97 MCH-31.9 MCHC-33.1 RDW-18.2* Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-175* UreaN-30* Creat-1.7* Na-143
K-4.4 Cl-104 HCO3-28 AnGap-15
___ 05:50AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
MICROBIOLOGY
=============
___ 3:44 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
FOSFOMYCIN REQUESTED BY ___. ___ ___.
ZONE SIZE FOR FOSFOMYCIN IS 22 MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
RADIOLOGY
===========
(PER ORTHO ADMISSION NOTE) IMAGING: Plain film imaging of the
LLE demonstrates an angulated, spiral pattern distal tibia
fracture which does not extend to the ankle joint, with
concomitant proximal fibula fracture.
CXR ___
In comparison with the study of ___, there are continued low
lung
volumes. Mild atelectatic changes are seen at the bases,
without definite vascular congestion or pleural effusion.
Of incidental note are old healed fractures of several left
ribs, prosthetic right shoulder, and metallic device projected
over the midline at the lower cardiac level.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Nasonex (mometasone) 50 mcg/actuation nasal daily
5. Sertraline 50 mg PO DAILY
6. CloniDINE 0.2 mg PO BID
7. ALPRAZolam 1 mg PO TID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Temazepam 15 mg PO HS:PRN insomnia
10. Gabapentin 900 mg PO TID
11. Calcitriol 0.25 mcg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. CeleBREX (celecoxib) 200 mg oral daily
15. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Calcitriol 0.25 mcg PO DAILY
2. CloniDINE 0.2 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Ranitidine 150 mg PO BID
10. Sertraline 50 mg PO DAILY
11. Enoxaparin Sodium 30 mg SC Q24H Duration: 11 Days
Start: ___, First Dose: Next Routine Administration Time
12. Multivitamins 1 CAP PO DAILY
13. Nasonex (mometasone) 50 mcg/actuation nasal daily
14. Amlodipine 10 mg PO DAILY
15. ALPRAZolam 1 mg PO TID
16. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Dose
Dissolve in ___ oz (90-120 mL) water and take immediately
To be given on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Left tibia/fibula fracture
Hypertension
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
HISTORY: Status post fall with memory impairment. Evaluate for intracranial
hemorrhage.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal and sagittal
and thin section bone algorithm-reconstructed images were acquired.
DLP: 891 mGy-cm.
CTDIvol: 55 mGy.
COMPARISON: None available.
FINDINGS: There is no hemorrhage, mass effect, midline shift, edema, or
evidence of acute large infarct. The ventricles and sulci are prominent,
indicative of global atrophy, age related. Periventricular white matter
hypodensities are likely a sequela of chronic small vessel ischemic disease.
Additionally, focal hypodensity in the right lentiform nucleus may represent a
prior lacunar infarct or a prominent perivascular space.
No fractures identified. Minimal mucosal thickening in the ethmoid sinuses
bilaterally, otherwise the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are remarkable for bilateral lens
resection. Vascular calcifications are noted at the carotid siphons and
vertebral arteries bilaterally.
IMPRESSION: Chronic changes with otherwise no acute abnormality.
Radiology Report
HISTORY: ___ male with left tibial fibular fracture.
COMPARISON: MR dated ___
FINDINGS:
Fluoroscopic assistance was provided to this surgeon without a radiologist
present. ___ spot views were obtained. These demonstrate internal
fixation of distal end tibial and fibular fractures. For details, please
refer to operative report in ___ medical record.
IMPRESSION:
As above.
Radiology Report
HISTORY: Pneumonia or edema.
FINDINGS: In comparison with the study of ___, there are continued low lung
volumes. Mild atelectatic changes are seen at the bases, without definite
vascular congestion or pleural effusion.
Of incidental note are old healed fractures of several left ribs, prosthetic
right shoulder, and metallic device projected over the midline at the lower
cardiac level.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT TIB-FIB FX
Diagnosed with FX ANKLE NOS-CLOSED, FX UPPER END FIBULA-CLOS, OTHER FALL, HYPERTENSION NOS
temperature: 97.3
heartrate: 44.0
resprate: 16.0
o2sat: 96.0
sbp: 152.0
dbp: 52.0
level of pain: 3
level of acuity: 3.0 | ___ man with HTN, CKD, hypothyroidism, anxiety/depression,
borderline DM presenting after a mechanical fall, found to have
left distal tibia, proximal fibula fracture now s/p repair as
well as UTI and normocytic anemia.
ACTIVE ISSUES
==============
# Tibia/Fibula Fracture
Now s/p repair by orthopedics. Will continue enoxaparin for a
total 2 week course. Will f/u with orthopedics in two weeks
(___). Now in splint, LLE is non-weight bearing, okay
for touch down. Pain control with tylenol.
# O2 requirement
Patient has developed new O2 requirement after surgery. Most
likely due to atelectasis. Was weaned back to RA and O2 sats
were 93% on RA on the day of discharge.
# Hyperkalemia
Potassium noted to be 5.0 upon admission. Was recently noted to
be 4.6 on outpatient labs. Was as high as 5.7 during admission-
no EKG changes noted. Decreased with kayexalate and was 4.4 on
the day of discharge.
# S/p Fall
Per history, most likely mechanical in nature, CT head negative.
No further workup at this time.
# UTI
Patient denied any dysuria; however, UA noted to have large ___,
nitrites and >172 WBC. Was initially treated with Cefazolin
given this was also used as postop ppx. Was then transitioned
to Cefpodoxime, however, sensitivities came back on ___
showing a MDR pseudomonal UTI. Was treated with Ceftazadime for
1 day on ___. Sensitivities then came back showing
sensitive to Fosfoymcin- he received 1 dose on ___ and will
receive one more dose on ___.
# Leukocytosis
WBC noted to be elevated at 12.6 upon admission. Remained
elevated throughout admission and ultimately thought to be due
to stress versus UTI as above.
# Anemia
Per outpatient records, most recent H/H was 9.9/31.8. Per PCP,
this is thought to be due to his CKD. H/H 9.7/29.5 upon
admission. On ___ H/H noted to be 7.0/21.4 without any
active signs of bleeding. Patient was transfused one unit of
pRBCs and his Hct bumped appropriately.
# ___ on CKD
Per recent records, Cr 2.07 as of most recent PCP progress note.
Upon admission, Cr was 2.4- thought to be due to pre-renal
azootemia in the setting of fall and likely poor PO intake. On
the day of discharge, Cr had trended down to 1.7.
# Orthostatic Hypotension
Patient was noted to be orthostatic during admission. This was
felt to be due to volume depletion due to poor PO intake
immediately following surgery. He received several small
boluses of 500cc NS and orthostatics were negative on the day of
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Norvasc
Attending: ___.
Chief Complaint:
Hypoxia and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with hx. COPD on home ___, pulmonary HTN,
hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p
repair presenting with c/o weakness.
Patient reports fatigue and weakness starting 1 week ago. Says
has been going on gradually but worsened over last week. For
the last 2 weeks she has increased ___ oxygen use - used to be
only at night now pretty much all the time. Has had associated
increase in clear sputum production, mostly in the AM. Denies
fevers or chills, no sick contacts. No chest pain or
palpitations. No weight gain, denies orthopnea or PND. At ___
baseline she could walk to ___ car from ___ house without
oxygen, but now is too fatigued to complete even simply
activities.
In the ED, initial vitals: 98.6 65 147/87 16 81% RA. Labs were
notable for a CBC with WBC 3.2, plt 88, nl trop/BNP, chem-7 with
Cl 95, Bicarb 44. CXR showed cardiomegaly and no signs of
pneumonia. Patient was given duonebs, methylpred 125mg IV, as
well as full dose aspirin.
Upon arrival to the floor patient says she feels better. Denies
dyspnea, wheezing, or chest pain. No other complaints.
Past Medical History:
1. Aneurysm of ascending aorta and aortic arch, s/p repair ___
2. Tortuous dilated thoracic aorta.
3. HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR,
1+MR
5. L vocal cord dysphagia- ___
6. Hypertension.
7. Hypercholesterolemia.
8. Diabetes mellitus, type 2.
9. Hypothyroidism.
10. Glaucoma.
11. Osteoarthritis.
12. Osteopenia
13. Status post total abdominal hysterectomy.
14. Status post colonic polypectomy.
15. h/o Left Nasolabial abscess, s/p excision. (___)
16. Status post thoracic aortic stent graft repair for posterior
penetrating ulcer.
17. Euthyroid multinodular goiter (left-sided dominant ~3cm
solid nodules FNA negative for malignancy).
18. ? h/o asthma
19. ? h/o Tb work-up
Social History:
___
Family History:
Father, deceased, possibly due to cancer. Mother, deceased, died
during childbirth when Ms. ___ was approximately ___ years old.
Reports that family members on maternal side have
characteristically "died young." Sister with ___, and another
sister who died in ___ ___ of cancer, though she does not recall
the type.
Physical Exam:
ADMISSION EXAM
Vitals- 98.2 159/57 hr 78 17 96% 2L
General- awake, alert, in NAD but mildly tachypneic
HEENT- PERRLA, EOMI, OMM no lesions
Neck- supple, JVD elevated to manible at 30 degrees
Lungs- expiratory wheezing b/l, no crackles
CV- RRR, 2+ systolic murmur RUSB
Abdomen- soft, NT/ND 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, strength ___ in UE and ___ b/l
DISCHARGE EXAM
Vitals- 99 120/51 69 18 96% 2L
General- awake, alert, NAD, mildly tachypneic
HEENT- PERRLA, EOMI, OMM no lesions
Neck- supple, JVD elevated to manible at 30 degrees
Lungs- mild expiratory wheezing b/l, no crackles
CV- RRR, 2+ systolic murmur RUSB
Abdomen- soft, NT/ND 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- grossly intact
Pertinent Results:
___ LABS
___ 06:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 06:00PM URINE RBC-3* WBC-16* BACTERIA-FEW YEAST-NONE
EPI-1
___ 03:20PM BLOOD WBC-3.2* RBC-4.59 Hgb-12.6 Hct-40.7
MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt Ct-88*
___ 03:20PM BLOOD Plt Smr-LOW Plt Ct-88*
___ 03:20PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-145
K-4.2 Cl-95* HCO3-44* AnGap-10
___ 03:20PM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0
___ 03:53PM BLOOD ___ Temp-36.6 pO2-43* pCO2-86*
pH-7.37 calTCO2-52* Base XS-19 Intubat-NOT INTUBA
___ 03:53PM BLOOD Lactate-1.3
PERTINENT LABS
___ 03:20PM BLOOD proBNP-554
___ 03:20PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 06:35AM BLOOD WBC-5.3# RBC-4.14* Hgb-11.5* Hct-36.5
MCV-88 MCH-27.7 MCHC-31.4 RDW-16.4* Plt Ct-90*
___ 06:35AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-147*
K-3.6 Cl-98 HCO3-46* AnGap-7*
___ 06:35AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
MICRO
NONE
REPORTS
___ Imaging CHEST (PORTABLE AP)
IMPRESSION: No definite acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Amlodipine 5 mg PO DAILY
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Vitamin D 50,000 UNIT PO 2X/MONTH
6. HydrALAzine 50 mg PO BID
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Pilocarpine 1% 1 DROP BOTH EYES Q8H
11. Travatan Z (travoprost) 0.004 % ophthalmic QHS
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. HydrALAzine 50 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Pilocarpine 1% 1 DROP BOTH EYES Q8H
8. Azithromycin 250 mg PO Q24H Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
13. Travatan Z (travoprost) 0.004 % ophthalmic QHS
14. Vitamin D 50,000 UNIT PO 2X/MONTH
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ female with dyspnea.
COMPARISON: ___.
FINDINGS: The cardiac silhouette is severely enlarged and there is a stent
graft within the known thoracic aortic aneurysm. The lungs are grossly clear
without large confluent consolidation.
IMPRESSION: No definite acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hypoxia
Diagnosed with HYPOXEMIA, PULMONARY HTN-SECONDARY
temperature: 98.6
heartrate: 65.0
resprate: 16.0
o2sat: 81.0
sbp: 147.0
dbp: 87.0
level of pain: nan
level of acuity: 1.0 | ___ year old female with hx. COPD on home ___, pulmonary HTN,
hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p
repair presenting with c/o weakness
#Hypoxia: Ms. ___ was hypoxic to low ___ on arrival to ED and
mid ___ on home 2L on arrival to floor. Given progressive
requirement in home oxygen, likely etiology is acute on chronic
COPD. There was low concern for pulmonary embolism given
gradual onset and lack of tachycardia or heart failure (normal
BNP). She was treated with albulterol and ipratropium
nebulizers, prednisone 40mg x5 days (last day ___, and
azithromycin x5 days (last day ___. On day of discharge, ___
breathing was subjectively returned to baseline and O2
saturation was mid-90s on home O2 (2L).
#Acute on chronic COPD exacerbation: Patient has severe baseline
COPD. Given ___ increased O2 requirement and sputum production
at time of admission, she was treated for COPD exacerbation as
outlined under Hypoxia. Supplemental O2 was continued to reach
goal saturation of low to mid-90s.
#Fatigue/weakness: Likely etiology of patient's fatigue and
weakness is COPD exacerbation. TSH was recently normal in
___ and she had no signs or symptoms of acute coronary
syndrome or acute blood loss. She was treated for COPD
exacerbation as outlined above.
#Alkalosis: Patient's alkalosis is likely chronic in setting of
severe COPD. VBG was indicative of CO2 retention (pCO2 86) that
is worse than prior. Contraction alkalosis was also considered
but was less likely. She was treated for COPD as above.
#Pulmonary HTN: Patient had an ECHO in ___ that demonstrated
mild-moderate mitral regurgitation, moderate tricuspid
regurgitation, and moderate pulmonary arterial systolic HTN.
Etiology is likely multifactorail in setting of cardiac and lung
disease. Patient had signs of TR on exam (JVP elevated to level
of mandible), but no peripheral edema to suggest right sided
heart failure. ___ cardiac status was monitored by physical
exam.
#Aortic aneurysm/ulcer: Patient is s/p ascending aortic
replacement and graft stent repair for penetrating ulcer. CXR on
admission demonstrated stable cardiomegaly.
#Leukopenia, thrombocytopenia: Etiology for these is unclear.
She has had thrombocytopenia in the past. This could represent
MDS. ___ blood counts were monitored as an inpatient. WBC count
normalized from 3.2 to 5.3 on day of discharge and platelet
count remained stable in ___.
TRANSITIONAL ISSUES
# will complete course of antibiotics and prednisone, total 5d
each
# CODE STATUS: DNR/DNI
# CONTACT: ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck swelling and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of smoking, intermittent chest
discomofort and recent worsening mediastinal lymphadenopathy on
chest CT chest who presents with worsening left neck pain and
swelling over weeks.
He returned today from ___ for concerns of swelling to left
sided neck over the last two weeks. He denies dyspnea, reports
some mild difficulty swallowing and mild pain with swallowing.
Patient denies chest pain. Reports was scheduled to have a CT on
___ of neck, and biopsy next week for concerns of swollen
lymph nodes in chest recently. patient denies fevers, chills,
dizziness, lightheadedness, nasuea, vomiting, diarrhea, SOB,
abdominal pain or dysuria.
Patient is followed by Pulm for Hx of borderline mediastinal
adenopathy with plans for EBUS ___. Patient former smoker with
25 pack year history. No fever, dysphagia, cough, chest pain,
weight loss, or night sweats. Patient had dental work ___ weeks
ago on the left side lower mandible.
In the ED, initial VS were 5 97.7 96 138/87 18 100%
Exam notable for lungs CTAB. Firm, tender left submandibular
swelling with erythema extending from the overlying area to the
clavicle.
Labs showed H/H ___, UA clean, WBC 7.1 Lactate 1.5
CT neck with contrast showed necrotic lymph node measuring 2.2 x
3.4 cm just superior to the left submandibular gland with
cervical, submandibular, and upper mediastinal lymph nodes.
Constellation of findings is concerning for malignancy such as
lymphoma or squamous cell carcinoma.
IP was consulted and ___ d/w attending Dr ___ EBUS ___
could be reschedule sooner vs FNA of submandibular necrotic mass
by ___.
Received IV Vancomycin 1000 mg in the ED
Transfer VS were 2 99.1 82 133/74 18 100% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient endorses the above history.
Asking for pain medications, feels fatigued as he recently
arrived from ___.
Past Medical History:
GERD
Bronchitis
SURGICAL HISTORY
___ - total hip replacement
___ laminotomies
___ - L shoulder
___ - R-shoulder
Social History:
___
Family History:
Father with prior small cell lung carcinoma
Multiple family members with colorectal cancer
Physical Exam:
On Admission
Vitals - 99.2 131/70 84 18 99%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, MMM, good dentition, no dental abscessess
appreciated
NECK: nontender supple neck, ~3cmx5cm fixed left submandibular
firm swelling with extention under chin with overlaying erythema
non fluctuant, outlined,
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, otherwise grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
On Discharge
Vitals- Tc 97.8 Tm 99.2 106-131-64-70 ___ 18 98-99%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear though hard to
visualize.
Neck- supple, ~3cmx5cm fixed left submandibular swelling,
painful and firm, extending under chin with overlaying erythema,
outlined.
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, normoactive bowel
sounds present, no rebound tenderness or guarding
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal
Pertinent Results:
On Admission
___ 01:00PM BLOOD WBC-7.1 RBC-4.14* Hgb-12.0* Hct-36.9*
MCV-89 MCH-29.0 MCHC-32.5 RDW-14.1 RDWSD-45.2 Plt ___
___ 01:00PM BLOOD Neuts-75.1* Lymphs-10.9* Monos-12.0
Eos-0.8* Baso-0.6 Im ___ AbsNeut-5.33 AbsLymp-0.77*
AbsMono-0.85* AbsEos-0.06 AbsBaso-0.04
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-105* UreaN-23* Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-26 AnGap-16
___ 01:30PM BLOOD Lactate-1.5
On Discharge
___ 06:10AM BLOOD WBC-5.3 RBC-3.77* Hgb-11.0* Hct-34.2*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.2 RDWSD-46.7* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-140
K-4.4 Cl-102 HCO3-29 AnGap-13
___ 06:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
Imaging:
___ CT Neck with Contrast
Necrotic 2.2 x 3.4 cm lymph node with scattered lymphadenopathy
is concerning for malignancy such as lymphoma or squamous cell
carcinoma. Superimposed infection is not entirely excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 2 mg PO HS
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 80 mg PO QPM
5. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral
DAILY
Discharge Medications:
1. Doxazosin 2 mg PO HS
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 80 mg PO QPM
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*20 Tablet Refills:*0
6. calcium carbonate-vit D3-min 600 mg (1,500 mg)-400 unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Neck pain, swelling
SECONDARY
Hypertension
Hyperlipidemia
Gastroesophageal reflux
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: ___ with ___ days of left submandibular swelling and erythema
c/f abscess // assess for 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: Total DLP (Body) = 519 mGy-cm.
COMPARISON: CT chest ___
FINDINGS:
Evaluation is somewhat limited by dental hardware.
Just superior to the left submandibular gland there is a 2.2 x 3.4 cm
(transverse by AP) centrally hypodense soft tissue structure concerning for
necrotic mass and there is mild adjacent soft tissue edema. Superimposed
infection is not entirely excluded. The airways patent. Extensive cervical
and submandibular lymphadenopathy with scattered prominent mediastinal lymph
nodes. The thyroid gland appears normal.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
IMPRESSION:
Necrotic 2.2 x 3.4 cm lymph node with scattered lymphadenopathy is concerning
for malignancy such as lymphoma or squamous cell carcinoma. Superimposed
infection is not entirely excluded.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: L Neck pain
Diagnosed with CELLULITIS OF HAND, SWELLING IN HEAD & NECK
temperature: 97.7
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 138.0
dbp: 87.0
level of pain: 5
level of acuity: 3.0 | ___ is a ___ year old male with history of smoking,
worsening mediastinal lymphadenopathy on chest CT (___), who
presented with a tender, swollen neck with imaging concerning
for malignancy but could not rule out infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents / contrast dye
Attending: ___.
Chief Complaint:
Leg/abdominal/L arm swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history CKD (baseline Cr ~4), s/p
descending aortic dissection repair in ___ requiring ileostomy
on TPN, HTN, and anxiety/depression who presents to ___ after a
recent admission for LLL PNA (discharged ___ now with
increasing leg and abdominal swelling over the past ___ days.
Patient states that after she was discharged from the hospital
___, she was unable to make a follow-up appointment with her
PCP ___ due to fatigue. During this time she also describes
some chills and an ongoing cough production of white sputum
(improved since last week when there was green sputum, blood
tinged). She decided to call an ambulance yesterday due to
progressing leg swelling and abdominal distension, symptoms
about which she had been warned by her prior inpatient team. Of
note, she denies any worsening SOB, stating that overall her
respiratory status has improved after being treated for the
pneumonia. No ongoing CP or palpitations.
Patient denies any abdominal pain or N/V. Ostomy output has
been decreased in the setting of poor PO intake. Patient
endorses generalized weakness, though she was up and able to
walk at home. No dysuria/frequency. ROS otherwise NEG.
In the ED, initial vital signs were: T 98.6 P 86 BP 150/81 R 16
O2 sat ___ on RA, high ___ on 2LNC.
- Exam notable for: Bilateral ___ edema
- Labs were notable for Cr 4.6(at baseline), BNP 1818, hgb
7.2(recent baseline)
- Studies performed include:
CXR
1. Mild pulmonary vascular congestion without frank edema.
2. Persistent left basilar consolidation, again concerning for
pneumonia.
3. Small left pleural effusion.
4. Changes associated with history of thoracic aorta aneurysm
and dissection.
- Patient was given 20mg IV Lasix
Upon arrival to the floor, the patient recounts the above story.
She denies any acute worsening of SOB. Her main complaints are
weakness and swelling in her legs. She does note that her R arm
is chronically, intermittently swollen s/p TPN catheterization
in the past. Her current TPN catheter is a L fem line, she
denies any pain, swelling, or redness in the area.
Past Medical History:
1. Descending Aortic Dissection ___, s/p repair, c/b bowel
ischemia and resection (right/transverse colon and partial SB
resection due to mesenteric ischemia in ___.
2. S/p Open cholecystectomy ___.
3. Stage IV sacral Decub (MRSA/VRE)
4. Short gut syndrome, on TPN
5. Bilateral Pneumothorax
6. h/o of G/J tube now removed
7. Anxiety
8. Depression
9. HTN
10. h/o hepatitis
11. h/o Pancreatitis
12. h/o HIT ab
13. h/o MRSA line infection (___)
14. h/o Klebsiella bacteremia ___ as a complication of
cholecystectomy)
15. H/o MRSA bacteremia (___)
16. H/o spontaneous vertebral fractures (pain control w/morphine
17. ___ abnormal liver chemistries and liver biopsy showing
mild-to-moderate lobular mononuclear cell inflammation, bile
duct proliferation and focal canalicular cholestasis, mild
steatosis and a slight increase in portal fibrosis. This is
consistent with TPN-related liver injury
b/l UE DVT
Social History:
___
Family History:
Mother: HTN
Grandmother: HTN
Physical Exam:
ADMISSION PHYSICAL
=================
Vitals- 99.4, 150s/70s, 70s-80s, ___, 95 on 2L
GENERAL: AOx3, NAD
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Oropharynx
is clear with MMM.
NECK: No cervical/submandibular/supraclavicular lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, ___ holosystolic murmur
best heard at ___, no rubs/gallops. No JVD.
LUNGS: Decreased breath sounds and scattered inferior
inspiratory crackles in lower lung fields bilaterally.
ABDOMEN: Normal bowels sounds, non distended, diffuse
tenderness to deep palpation. Ileostomy in RLQ, tissue well
vascularized. No HSM.
EXTREMITIES: Pulses DP/Radial 1+ bilaterally. 1+ ___ to mid
shins bilaterally. L fem line cdi. LUE with 1+ edema.
SKIN: No evidence of ulcers, rash or lesions.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia.
DISCHARGE PHYSICAL
=================
99.7, 148-164/70-88, 70-87, ___ ON RA
GENERAL: AOx3, NAD
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Oropharynx
is clear with MMM.
NECK: No cervical/submandibular/supraclavicular lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, ___ holosystolic murmur
best heard at ___, no rubs/gallops. No JVD.
LUNGS: Decreased breath sounds and scattered inferior
inspiratory crackles in lower lung fields bilaterally, scattered
wheeze.
ABDOMEN: Normoactive bowels sounds, non distended, diffuse
tenderness to deep palpation. Ileostomy in RLQ, tissue well
vascularized. No HSM.
EXTREMITIES: Pulses DP/Radial 1+ bilaterally. No ___. L fem
line cdi. LUE with 2+ edema.
SKIN: No evidence of ulcers, rash or lesions.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia.
Pertinent Results:
ADMISSION LABS
=============
___ 03:30AM BLOOD WBC-6.9 RBC-2.69* Hgb-7.2* Hct-22.2*
MCV-83 MCH-26.8 MCHC-32.4 RDW-13.4 RDWSD-40.6 Plt ___
___ 03:30AM BLOOD Neuts-77.0* Lymphs-7.0* Monos-13.3*
Eos-1.9 Baso-0.4 Im ___ AbsNeut-5.27 AbsLymp-0.48*
AbsMono-0.91* AbsEos-0.13 AbsBaso-0.03
___ 03:30AM BLOOD Plt ___
___ 03:30AM BLOOD Glucose-158* UreaN-89* Creat-4.6* Na-138
K-3.4 Cl-95* HCO3-28 AnGap-18
___ 07:00PM BLOOD Glucose-86 UreaN-87* Creat-4.8* Na-139
K-3.6 Cl-96 HCO3-29 AnGap-18
___ 03:30AM BLOOD proBNP-1818*
___ 07:00PM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1
___ 06:15AM URINE Color-Straw Appear-Clear Sp ___
___ 06:15AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:15AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 06:15AM URINE Mucous-RARE
MICRO
=====
___ 6:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-7.0 RBC-2.64* Hgb-7.4* Hct-21.9*
MCV-83 MCH-28.0 MCHC-33.8 RDW-13.2 RDWSD-40.4 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-123* UreaN-77* Creat-4.6* Na-141
K-3.7 Cl-97 HCO3-30 AnGap-18
___ 06:00AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2
IMAGING/STUDIES
==============
FINDINGS:
Heart size is normal. There are midline sternotomy wires. The
aorta is
calcified, indicating atherosclerosis. Again seen is a
lobulated contour
abutting the aortic arch in projecting over the AP window,
compatible with
thoracic aortic aneurysm and prior dissection. There is mild
pulmonary
vascular congestion without frank edema. Underlying
emphysematous changes.
Again seen is left basilar consolidation, concerning for
pneumonia. Small
left pleural effusion. No pneumothorax. There are no acute
osseous
abnormalities.
IMPRESSION:
1. Mild pulmonary vascular congestion without frank edema.
2. Persistent left basilar consolidation, again concerning for
pneumonia.
3. Small left pleural effusion.
4. Changes associated with history of thoracic aorta aneurysm
and dissection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 100 mg PO BID
5. Carvedilol 37.5 mg PO BID
6. Meclizine 12.5 mg PO Q6H:PRN frequent dizziness
7. Minoxidil 5 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. TraZODone 50 mg PO QHS:PRN Sleep
11. Ursodiol 600 mg PO BID
12. Vitamin D ___ UNIT PO 1X/WEEK (WE)
13. Metoclopramide 10 mg PO TID:PRN nausea
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze
15. Space Chamber Plus (inhalational spacing device) 1 spacer
miscellaneous as directed
16. Sodium Bicarbonate 650 mg PO BID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. TraZODone 25 mg PO QHS:PRN Sleep
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. BuPROPion (Sustained Release) 100 mg PO BID
9. Carvedilol 37.5 mg PO BID
10. Meclizine 12.5 mg PO Q6H:PRN frequent dizziness
11. Metoclopramide 10 mg PO TID:PRN nausea
12. Minoxidil 5 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Sodium Bicarbonate 650 mg PO BID
15. Space Chamber Plus (inhalational spacing device) 1 spacer
miscellaneous as directed
16. Ursodiol 600 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnosis
=================
Chronic Kidney Disease
Hypoxia
Secondary Diagnoses
===================
Hypertension
Normocytic Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with sob // ?pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Heart size is normal. There are midline sternotomy wires. The aorta is
calcified, indicating atherosclerosis. Again seen is a lobulated contour
abutting the aortic arch in projecting over the AP window, compatible with
thoracic aortic aneurysm and prior dissection. There is mild pulmonary
vascular congestion without frank edema. Underlying emphysematous changes.
Again seen is left basilar consolidation, concerning for pneumonia. Small
left pleural effusion. No pneumothorax. There are no acute osseous
abnormalities.
IMPRESSION:
1. Mild pulmonary vascular congestion without frank edema.
2. Persistent left basilar consolidation, again concerning for pneumonia.
3. Small left pleural effusion.
4. Changes associated with history of thoracic aorta aneurysm and dissection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: B Leg swelling, B Arm swelling, Chest pain
Diagnosed with Heart failure, unspecified
temperature: 98.1
heartrate: 100.0
resprate: 16.0
o2sat: 93.0
sbp: 157.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ with history CKD (baseline Cr ~4), s/p
descending aortic dissection repair in ___ requiring ileostomy
on TPN, HTN, and anxiety/depression who presented to ___ after
a recent admission for LLL PNA (discharged ___ now with
increasing leg and abdominal swelling.
# Increasing leg and abdominal swelling - Exam initially
concerning for volume overload given ___ edema and inspiratory
crackles on exam, new O2 requirement of 2L, CXR though without
frank edema. Hypervolemia more likely in setting of worsening
CKD or fluid overload in the setting of recent treatment of
pneumonia. Felt less likely to be new CHF (last TTE ___,
low-normal LVEF 50%, mild MR and moderate TR). Patient received
IV Lasix 20mg x3 with rapid improvement of symptoms. She was
discharged on Lasix 20mg po daily, and was advised to monitor
daily weights.
# Hypoxia - Patient initially with sats in high ___ to low ___
on RA. She denied any subjective dyspnea, breathing much
improved s/p treatment for CAP last week. There may have been
some component of volume overload as mentioned above. Worsening
pulmonary infectious process unlikely given that patient was
afebrile, without leukocytosis.
# Left Upper Extremity Swelling - Patient has had waxing and
waning swelling of this limb in the past, most likely in setting
of central venous manipulation while receiving TPN. Last US on
___ was NEG for DVT.
# CKD - Cr slightly improved since last admission, although
increased from baseline of 4.1 in ___. Patient will likely
need dialysis soon and has had follow-up appointment scheduled
___ with transplant for consideration of a Hero graft. Previous
vein mapping showed no good targets for fistula placement.
# HTN
- Continued Carvedilol 37.5 mg PO/NG BID
- Continued Amlodipine 10 mg PO/NG DAILY
- Continued Minoxidil 5 mg PO DAILY
# Normocytic anemia - Baseline anemia likely secondary to CKD,
should likely start Darbepoiten. Hb at baseline ~7.2. She did
require a transfusion of 1U PRBCs during her last admission.
# GERD
- Decreased Omeprazole to 40qd
# Short gut syndrome, on TPN
- Nutrition consulted, continued TPN via L femoral central line
# History of HIT
- Mechanical DVT ppx with TEDS
# Depression
- Continued on home buproprion
TRANSITIONAL ISSUES
===================
- Patient started on Furosemide 20mg po daily
- Discharge weight: ___
- Patient with stable, though profound normocytic anemia in
setting of CKD, she should be started on Darbepoiten as
outpatient (will follow-up with renal ___
============================
#Code Status: Confirmed full
#Contact: ___ ___ |
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, polymorphic VT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ gentleman with history of alcohol
dependence, insulin-dependent diabetes, depression, anxiety,
chronic pancreatitis, hypertension and hyperlipidemia who
arrives via EMS from home with c/o CP and lightheadedness with
malaise. Noted to have transient polymorphic VT by EMS.
He reported that for the past ___ days he has been feeling
progressively worse with chest pain consistent with heartburn,
nausea & vomiting, dizziness & lightedheadess (esp. with
standing). Today ___, he felt acutely worse with all of these
symptoms and called EMS, who brought him to the ED.
In this setting, as per EMS patient had several and frequent
runs of Vtach ranging in ___ beats. On arrival to ED, labs
showed hypomagnesemia, hypokalemia, alkalosis in the setting of
prolonged QTc. Patient is taking citalopram 40 mg daily, and
quetiapine, both QTc prolonging medications.
Patient stated that he had had approximately 1 week of
decreased appetite with diarrhea and then nausea and vomiting
with the symptoms noted above. Stools have been light colored,
but nonbloody and no melena.
"Chest pain" is located in the mid-epigastrium and central
chest. Patient states it feels like heartburn he has had in the
past. He notes that with TUMS the pain resolves, but only for a
short time. Maalox is also helpful.
Of note, patient also with history of alcoholism with
withdrawal and daily drinking. Last drink was 1 beer on ___
___ at 14:00. He has been "detoxing" from EtOH with psychiatric
care.
Patient has also had previous electrolyte abnormalities. The
patient declined to address these abnormalities however to focus
on abstinence and psychiatric issues. These previous labs
included K 3.4, hyponatremia, hypochloremia, and low bicarb with
transaminitis.
In the ED initial vitals were: Temp 98.4 HR 104 BP 126/85 RR 16
100% RA
EKG: sinus rhythm, prolonged qtc to 597ms initially
Labs/studies notable for:
Na 129
K 3.2
Cl 87
BUN 3
Cr 0.7
Ca 8.3
Mg 1.2
P 3.2
AST 107
ALT 55
AP 36
Tbili 0.7
Albumin 2.5
WBC: 10.6
Hgb: 10.5, Hct 32.4
Plt 302
VBG: pH 7.59; pCO2 32; HCO3 32
Trop x 1 <0.01
___: 14.9 PTT: 30.7 INR: 1.4
UA: glucose 1000
Cardiology was consulted and recommended:
- Replete electrolyte to K>4.0 and Mg>2.0
- avoid QT prolonging medication.
- Admit to ___ 3.
Patient was given:
___ 16:38 IV Magnesium Sulfate 2 gm
___ 17:09 IV Magnesium Sulfate 2 gm
___ 17:30 PO Potassium Chloride 40 mEq
___ 17:30 IVF 40 mEq Potassium Chloride / 1000 mL NS
started 250 mL/hr
___ 17:55 IV Thiamine 100 mg
___ 18:27 IV Calcium Gluconate 1 g
___ 18:27 IV Magnesium Sulfate 2 gm
___ 18:38 PO Aluminum-Magnesium Hydrox.-Simethicone 30
mL
___ 19:21 IV FoLIC Acid 1 mg
___ 19:39 SC Insulin 4 Units
Vitals on transfer: 91 142/92 18 100% Nasal Cannula
On the floor, patient complaining of severe ___ heartburn
pain and nausea, same character as before but more severe.
Denies fevers, chills, dyspnea.
Around 23:00, patient feeling anxious and tremulous--given
Ativan for WD symptoms.
Past Medical History:
-Insulin-dependent Type II Diabetes Mellitus
-Chronic Pancreatitis ___ to ETOH
-HTN
-Hyperlipidemia
-Alcohol Abuse
-Depression - history of suicide attempt ___ by
Listerine ingestion
-Generalized Anxiety
-Obstructive Sleep Apnea
-Erectile Dysfunction
-GERD
Social History:
Born/Raised: ___, raised in ___
Childhood: Struggled with school, father was abusive and
alcoholic
Income: Used to work at a psych unit at ___, has also worked
at a homeless ___, in drug/addiction facilities, and most
recently as a ___ at ___. Lost job over a year ago,
unemployed
Housing: lives with wife (second) of ___ years and 7, 8, and ___
y/o grandchildren whom are the children of his stepdaughter. ___
y/o daughter is in and out of house, getting ___ in
psychology
Education: through ___ grade, took special education classes
Relationships: supportive with wife, church, ___
Religion/Spirituality: was ___ ___ in church, formerly very
involved, feels guilty about not being continuously involved
Trauma: witnessed domestic violence in parents, abused by father
as child, physically abused by daughter's mother once in past
SUBSTANCE ABUSE HISTORY:
ETOH: history of dependence, no significant withdrawals or
seizure, had ___ y sober in 1990s with good mood during that
time, has been sober almost one year now but does occasionally
drink ___ oz beers to 'self-medicate' his anxiety (nothing
near his previous 1 pint brandy/day intake however)
MJ: last used ___ y ago
Cigarettes: 1-2/day
Other: denies
FORENSIC HISTORY: ___
Family History:
FAMILY PSYCHIATRIC HISTORY:
- Alcoholism: Father (deceased), Sister (also with bipolar,
depression, anxiety) currently stable on medications. Strong
Drinkers in ___ children.
- Depression: Mother (deceased ___
- No suicides in the family
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: T=98.5 BP=165/108 HR=123 RR=22 O2 sat=99% RA
GENERAL: Thin adult male, in pain. Alert and Oriented. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD.
CARDIAC: Tachycardic. Normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, mildly tender.
EXTREMITIES: No c/c/e. Right foot plantar laceration,
hemostatic and without purulence, nontender.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
PHYSICAL EXAM ON DISCHARGE:
===========================
Tele: HR 80-90s, with multiple spikes to SVT@130bpm, likely
with motion
VS: T98.0 (tmax 98.4) BP149/103 (100-160/90-108) HR92 (80s-120s)
RR18 O2 sat 99%RA
Weight: 61.1 (admit wt: n/a)
I/O: ___/void
Gen: pleasant, cooperative, appropriate, NAD, AAOx3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, 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. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Irregular 3-4 cm diameter wound on plantar surface of R heel
through full thickness of epidermis. no erythema,induration
around it
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:25PM WBC-10.6* RBC-3.96* HGB-10.5* HCT-32.4*
MCV-82 MCH-26.5 MCHC-32.4 RDW-14.7 RDWSD-43.5
___ 04:25PM GLUCOSE-307* UREA N-3* CREAT-0.7 SODIUM-129*
POTASSIUM-3.2* CHLORIDE-87* TOTAL CO2-30 ANION GAP-15
___ 04:25PM ALBUMIN-2.5* CALCIUM-8.3* PHOSPHATE-3.2
MAGNESIUM-1.2*
___ 04:25PM ___ PTT-30.7 ___
___ 04:25PM ALT(SGPT)-55* AST(SGOT)-107* ALK PHOS-306*
TOT BILI-0.7
___ 04:25PM PO2-105 PCO2-28* PH-7.65* TOTAL CO2-32* BASE
XS-10
___ 04:25PM LIPASE-5
___ 04:25PM ALT(SGPT)-55* AST(SGOT)-107* ALK PHOS-306*
TOT BILI-0.7
___ 04:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:25PM ___ PTT-30.7 ___
___ 06:21PM cTropnT-<0.01
___ 04:25PM cTropnT-<0.01
LABS ON DISCHARGE:
==================
___ 06:35AM BLOOD WBC-6.4 RBC-3.39* Hgb-9.0* Hct-28.7*
MCV-85 MCH-26.5 MCHC-31.4* RDW-15.6* RDWSD-47.7* Plt ___
___ 06:35AM BLOOD Glucose-388* UreaN-5* Creat-0.6 Na-135
K-4.3 Cl-100 HCO3-27 AnGap-12
___ 06:35AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
STUDIES:
========
TTE ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 65%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion
Exercise MIBI ___:
IMPRESSION: Poor exercise tolerance. No anginal symptoms or
ischemic ST segment changes. No exercise-induced VT. Blunted
blood pressure response to exercise. Tachycardic at rest with
appropriate heart rate response to exercise. Nuclear report sent
separately.
Nuclear study:
FINDINGS:
Left ventricular cavity size is normal with an end-diastolic
volume of 57 mL.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 63%.
IMPRESSION: 1. Normal cardiac perfusion.
2. Normal left ventricular cavity size and ejection fraction.
EKG: QTc on discharge 442ms. QTc on admission 597 ms.
___:
======
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Creon 12 4 CAP PO TID W/MEALS
6. Omeprazole 20 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO BID:PRN anxiety
8. Simvastatin 10 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Mirtazapine 15 mg PO QHS
take 15 mg on ___ and 30 mg starting ___ at night
RX *mirtazapine 30 mg ___ tablet(s) by mouth every night Disp
#*29 Tablet Refills:*0
4. TraZODone 50 mg PO BID:PRN anxiety
RX *trazodone 50 mg 1 tablet(s) by mouth twice a day as needed
Disp #*60 Tablet Refills:*0
5. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Aspirin 81 mg PO DAILY
7. Creon 12 4 CAP PO TID W/MEALS
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
==================
chest pain
polymorphic ventricular tachycardia
prolonged QT interval
electrolyte abnormalities
Secondary diagnosis:
====================
alcohol abuse
insulin dependent diabetes mellitus
anxiety
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with cp // ? effusion
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph on ___
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion.
IMPRESSION:
No acute cardiopulmonary abnormality
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Epigastric pain, Chest pain, Weakness
Diagnosed with Ventricular tachycardia, Hyperkalemia
temperature: 98.4
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 126.0
dbp: 85.0
level of pain: 8
level of acuity: 3.0 | ___ gentleman with history of alcohol dependence,
insulin-dependent diabetes, depression, anxiety, chronic
pancreatitis, hypertension and hyperlipidemia presenting with
chest pain, multiple electrolyte abnormalities and polymorphic
VT.
Mr ___ ruled out for ACS with negative troponins x3. TTE and
exercise MIBI also revealed poor exercise tolerance but
structurally normal heart with normal EF (65%). Chest pain
ultimately resolved with Maalox and tums, as well as with
improvement of electrolyte disturbances as described below.
On arrival, Mr ___ was noted to be in polymorphic VT that did
not require defibrillation. Electrolytes revealed hypomagnesemia
to 1.2, hypokalemia, hypochloremia, hypophosphatemia in the
context of recent nausea, vomiting, diarrhea. Patient also has
history of alcohol abuse raising concern for malnutrition as
well. Electrolytes were repleted aggressively and returned
within normal limits. Despite patient reporting that he had cut
down on his alcohol consumption to a can of beer every few days,
he was started on CIWA scale to prevent acute withdrawal
symptoms.
Of note, correction of electrolytes did not resolve prolonged QT
noted on EKG. It was noted that Mr ___ was taking citalopram
and quetiapine for his anxiety/depression, both of which are QT
prolonging medications. Both were held this hospitalization. At
discharge, QTc is 442ms, but review of old EKGs in the system
also suggests that patient may have prolonged QT at baseline. Mr
___ has remained completely asymptomatic.
Finally, given the discontinuation of quatiapine and citalopram,
Psychiatry was consulted for anxiety/depression management.
Patient was offered 50 mg Trazodone twice daily as needed for
anxiety and started on Mirtazapine 15 mg at night for
depression. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Methyldopa
Attending: ___
Chief Complaint:
Dyspnea, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of HTN,
CVA ___, R hemiparesis) who presented to the ED with chest
pain and dyspnea. The chest pain began last night at rest while
he was watching TV. It was substernal and without radiation to
the arm or neck. Several minutes later he developed shortness of
breath (at rest).
In the ED, initial vitals were: T97.6, HR 65, BP 148/64, RR 26,
98% RA, Pain ___. Exam was notable for wheezy lung sounds and a
respiratory rate of 34.
Labs notable for: WBC 11.6, Creatinine 1.3 (baseline 1.1-1.2),
troponin negative x1, BNP 1225.
EKG revealed: HR 62, low voltage in limb leads, normal axis,
delayed R wave progression (transition in V5), no distinct P
waves. Appears to be in an accelerated junctional rhythm.
CXR notable for: Cardiomegaly with increased interstitial
markings suggesting mild failure.
He received: Duonebs x3 with little improvement in symptoms,
respiratory rate remained ___. He was placed on Bipap and
received lasix 20mg IV x2. He respiratory status improved and
BiPAP was discontinued.
He is admitted to the ___ service for further management.
Vitals on transfer: 98.0 HR 70 BP 103/70 RR 20 95% 4L NC
Of note, the patient was recently seen by cardiology as an
outpatient for evaluation of atrial fibrillation which was first
identified in ___. He was started on diltiazem in addition to
metoprolol.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of syncope or
presyncope.
Past Medical History:
1. Prior CVA and intracranial hemorrhage (left basal ganglia
and left parietal regions, ___ at ___
2. Hypertension.
3. Hyperlipidemia.
4. Gout.
5. Atrial fibrillation (diagnosed ___
6. History of nephrolithiasis.
Social History:
___
Family History:
He does not think there is any family history of
sudden cardiac death or atrial fibrillation or cardiomyopathy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.4, 108/69, 73, 28, 96% on 4L NC
Weight: 100.1 kg
General: Middle aged male slightly dyspneic but speaking in full
sentences
HEENT: Anicteric sclera, PERRL, impaired right lateral gaze, MMM
Neck: Unable to discern JVP due to body habitus
CV: Soft heart sounds difficult to discern, no murmur/rub
Lungs: Crackles in bottom ___ of lung fields, no wheezes
Abdomen: NTND, soft
GU: No foley
Ext: Residual right sided ___ weakness but not markedly
different to left
Neuro: A&Ox3, impaired right lateral gaze, right homonymous
hemianopia.
PULSES: 2+ radial pulses and DP pulses
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.1, 120/78 (SBP 104-124), 65-87, 16, 97%RA
Weight: 91.7 kg
General: Middle aged male in NAD resting in bed
HEENT: Anicteric sclera, PERRL, impaired right lateral gaze, MMM
Neck: JVP not elevated
CV: Soft heart sounds difficult to discern, no murmur/rub
Lungs: Clear to auscultation, no w/r/r
Abdomen: NTND, soft
Ext: no edema, wwp
Neuro: A&Ox3, impaired right lateral gaze, residual right sided
___ weakness
PULSES: 2+ radial pulses and DP pulses
Pertinent Results:
==== ADMISSION LABS ====
___ 09:45AM BLOOD WBC-11.6* RBC-5.14 Hgb-17.8 Hct-51.2
MCV-100* MCH-34.6* MCHC-34.7 RDW-14.6 Plt ___
___ 09:45AM BLOOD Glucose-208* UreaN-28* Creat-1.3* Na-136
K-4.5 Cl-96 HCO3-24 AnGap-21*
___ 07:30PM BLOOD Mg-1.6
___ 09:45AM BLOOD proBNP-1225*
___ 09:45AM BLOOD cTropnT-<0.01
___ 07:30PM BLOOD CK-MB-4 cTropnT-<0.01
==== IMAGING ====
CXR (___):
Cardiomegaly with increased interstitial markings suggesting
mild failure. No
confluent consolidation or effusion.
TTE (___):
The left atrial volume index is severely increased. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened (?#) with focal
calcification of the non-coronary cusp. There is no aortic valve
stenosis. Mild to moderate (___) aortic regurgitation is seen
(moderate in the short axis view). The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, there is worse aortic, mitral and
tricuspid regurgitation. Global left ventricular systolic
function appears less vigorous, but still within normal range.
Pulmonary artery systolic pressure was not reported previously;
is moderately elevated on the current study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 80 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Metoprolol Tartrate 200 mg PO BID
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
4. Metoprolol Tartrate 200 mg PO BID
5. Pravastatin 40 mg PO QPM
6. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth qday Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Heart failure with preserved ejection fracture (HFpEF)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with dyspnea and chest pain // r/o acute process
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: None.
FINDINGS:
Increased interstitial markings are seen in the lungs. There is no confluent
consolidation or pleural effusion. Cardiac silhouette is moderately enlarged.
No acute osseous abnormalities.
IMPRESSION:
Cardiomegaly with increased interstitial markings suggesting mild failure. No
confluent consolidation or effusion.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ with a history of a left basal ganglia hemorrhage and left
parietooccipital ischemic strokes in ___, of unknown etiology, and Afib
diagnosed in ___, here with a CHF exacerbation undergoing consideration for
anticoagulation. // please assess stroke lesion load
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique.
COMPARISON: MRI head ___.
FINDINGS:
There is no acute infarct.
There is a chronic infarct with cystic encephalomalacia of the left parietal
and occipital lobes. Encephalomalacia has progressed since prior MRI on ___. There are foci of gradient susceptibility throughout the
infarct, consistent with chronic blood product deposition. There is associated
ex vacuo dilatation of the left lateral ventricle. The ventricles are
otherwise normal in size. There is a chronic infarct of the right occipital
lobe, much smaller than the left infarct. There is a chronic infarct of the
left basal ganglia with associated chronic blood products. There are numerous
foci of FLAIR hyperintensity throughout the subcortical, deep, and
periventricular white matter consistent with moderate chronic microangiopathy.
This has mildly progressed compared to prior MRI from ___. Major
intravascular flow voids are preserved.
Marrow signal is preserved. The paranasal sinuses and mastoid air cells appear
clear. The orbits are normal.
IMPRESSION:
1. Multiple chronic infarcts of the left parieto-occipital lobe, right
occipital lobe, and basal ganglia. There are chronic blood products associated
with some of these infarcts but no acute intracranial hemorrhage. No acute
infarct.
2. Moderate chronic microangiopathy, mildly progressed from prior MRI on ___.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, RESPIRATORY ABNORM NEC
temperature: 97.6
heartrate: 65.0
resprate: 26.0
o2sat: 98.0
sbp: 148.0
dbp: 64.0
level of pain: 2
level of acuity: 2.0 | ___ with a history of HTN, CVA ___, residual right sided
partial loss of motor function) who presents with brief (< 3
minutes) chest pain followed by SOB and hypoxemia, subsequently
found to be volume overloaded secondary to HFpEF exacerbation.
# HFpEF Exacerbation: Patient presented with lower extremity
edema, shortness of breath, pro-BNP 1225, increased interstitial
markings and cardiomegaly on CXR. He endorsed a 3 minute episode
of chest pain preceding the onset of his shortness of breath,
raising concern for cardiac ischemia as the precipitant of his
HFpEF exacerbation. However, troponins were negative x2 and EKG
without ischemic changes. TTE on ___ revealed preserved LVEF
>55%. Patient was diuresed approximately 10 liters net from
admission to discharge (dry weight 91.7kg). His weight remained
stable on Lasix 20mg PO qday and he was discharged on this dose
of diuretic. He will follow up with his PCP for ___ weight and
Chem-10 check within 7 days of discharge, and his cardiologist
within 3 weeks.
# Chest pain: Short duration (3 minutes). Unclear etiology.
Differential includes cardiac ischemia (troponin negative x2),
pulmonary embolism, anxiety secondary to shortness of breath
(although patient states the chest pain preceeded the SOB). He
underwent a pharmacologic nuclear cardiac stress test on ___
which was unremarkable.
# Atrial fibrillation: CHADS2 score of 4. Patient was not on
anticoagulation prior to admission due to prior hemorrhagic
stroke and concern regarding risk of recurrent bleeding on
anticoagulation. He was, however on ASA 325mg qday. On
admission, his rate-control consisted of diltiazem 240mg qday
(started on ___ by his cardiologist) and metoprolol tartrate
200mg BID. The stroke/neurology service was consulted during his
admission and recommended anticoagulation with a novel
anticoagulant (some data for reduced risk of ICH) *without*
concomitant use of aspirin. He was started on apixaban 5mg BID
on ___ and his aspirin was discontinued. He will follow up with
Dr. ___ (Cardiology) within 3 weeks.
==== TRANSITIONAL ====
# HFpEF (new diagnosis):
- PCP follow up within 1 week for a weight and Chem-10 check
within 7 days of discharge
- Cardiology follow up within 3 weeks
- Started on lasix 20mg PO qday
# Atrial Fibrillation
- Cardiology follow up in 3 weeks post-discharge
- Started apixaban 5mg BID for stroke prophylaxis given CHADS2
of 4
- Please consider whether this patient would benefit from
cardioversion
# ? Obstructive Sleep Apnea:
- Please strongly consider referral for outpatient sleep study
# Dry weight: 91.7 kg
# CODE: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Bilateral foot pain, wound evaluation
Major Surgical or Invasive Procedure:
Incision and drainage x2 ___
History of Present Illness:
___ male past medical history poorly controlled type 1
diabetes, active IVDU presenting with multiple complaints. His
primary complaint appears to be lesions that his back. There are
2 approximately 4 cm round raised lesions that he began noticing
2 days ago. Subjective fevers x2 days. States active IV drug
use, last injection yesterday. Prior to that had been abstinent
of IV drug use for 9 months secondary to incarceration.
Additionally complains of chronic worsening ulceration at right
great toe. Draining pus. Painful. Has been seen by podiatrist in
prison but none recently. He is a type I diabetic and states
that his last blood sugar measurement was read as high. States
difficulty obtaining insulin. Additionally complains of pruritic
lesions described as water blisters felt between his fingers.
- In the ED, initial vitals were: 98.7, 125/61, 95 bpm, 18, 97%
RA
- Exam was notable for:
Const: Comfortable, scratching himself
Eyes: No conjunctival injection
HENT: NCAT, Neck supple without meningismus
CV: RRR, Warm, well-perfused extremities. No murmur.
RESP: CTAB, Unlabored respiratory effort
GI: soft, non-tender, non-distended
MSK: No gross deformities appreciated
Skin: Warm, dry. 2 4cm round raised erythematous tender lesions
at R mid back. R great toe tender, ulcerated, erythematous.
Excoriation between fingers.
Neuro: Alert, Speech fluent
Psych: Appropriate mood and affect.
- Labs were notable for: WBC 12.6, Hgb 11.9, Na 126 (corrected
to 131), Glu 402, VBG 7.49/31
- Studies were notable for:
RIGHT FOOT X-RAY: Soft tissue ulceration along the plantar
aspect of the great toe at the level of the first IP joint
without radiographic evidence for osteomyelitis.
- The patient was given: Cefepime 2 g IV, Metronidazole 500 mg
IV, Insulin 6 u
- Podiatry and Social Work were consulted:
PODIATRY: Chronic right hallux ulceration that had macerated
edges debrided back to reveal granular base, no bone uncovered,
does not probe. No pus appreciated on exam. Swollen,
erythematous. Left plantar forefoot bulla with serous fluid - no
probing, no tracking. Recommend admission to medical service for
IV antibiotics - keep broad IV Vanc/Cefepime/Flagyl. No culture
taken as likely to yield skin flora - no pus. X-rays unchanged
from priors. Betadine dressing applied to both feet.
[]Admission to medical service given cellulitis
[]Betadine dressing to both feet
[]No plan for OR
SOCIAL WORK: Pt. is going to be admitted today, will refer to
social work and financial counseling to complete MA Health /HSN
application so that he can get meds.
On arrival to the floor, patient very agitated because he states
that he was treated very poorly in the ED. He wants to get help.
He endorses back pain as well as occasional fevers/chills. He
injected heroin into his left arm two days ago. He does not
share needles, does not lick needles; occasionally uses tap
water but mostly uses bottled water. He became intermittently
tearful alternating with anger with occasional euthymic mood
during our conversation.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
IDDM
Substance Use Disorder (crack, cocaine, heroin,
methamphetamines, benzos, EtOH)
HCV (untreated)
Depression w/self-reported multiple suicide attempts
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.2 PO BP: 142/77 R Sitting HR: 93
RR: 18 O2 sat: 95% O2 delivery: RA
GENERAL: Agitated but alert and interactive. Became more
cooperative with history and exam. Patient intermittently
itching.
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: Two large 3-4 cm tender erythematous lesions on back.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Right hallux TTP with erythema and swelling.
SKIN: Several excoriations all over skin. Track marks
antecubital fossa b/l.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
PSYCH: Extreme emotional lability.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 2329)
Temp: 99.0 (Tm 99.8), BP: 133/76 (108-133/67-76), HR: 80
(77-84), RR: 18, O2 sat: 100% (96-100), O2 delivery: Ra
GEN: sitting up in bed in NAD
HEENT: pupils bilaterally 3mm
___: RRR, nl S1/S2, no murmurs/rubs/gallops
PULM: CTABL no increased WOB
BACK: two 3-4 cm erythematous lesions both s/p I&D: both open
and packed, still tender
ABD: soft, NT/ND, +BS
EXTR: R hallux with betadine dressing, minimally TTP today
L forefoot with betadine dressing, minimally TTP
SKIN: excoriations improving. +track marks AC fossa b/l.
NEURO: AOx3, CN2-12 intact, moving all 4 limbs spontaneously,
___ strength bilaterally
PSYCH: affect appropriate, no longer labile
Pertinent Results:
ADMISSION LABS:
===============
___ 05:09PM BLOOD WBC-12.6* RBC-3.98* Hgb-11.9* Hct-32.5*
MCV-82 MCH-29.9 MCHC-36.6 RDW-12.6 RDWSD-36.5 Plt ___
___ 05:09PM BLOOD Neuts-69.4 Lymphs-16.4* Monos-11.0
Eos-2.4 Baso-0.4 Im ___ AbsNeut-8.75* AbsLymp-2.06
AbsMono-1.38* AbsEos-0.30 AbsBaso-0.05
___ 05:09PM BLOOD Glucose-402* UreaN-23* Creat-0.9 Na-126*
K-4.0 Cl-88* HCO3-22 AnGap-16
___ 05:17PM BLOOD ___ pO2-95 pCO2-31* pH-7.49*
calTCO2-24 Base XS-1 Comment-GREEN TOP
PERTINENT LABS:
===============
___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:11PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS* amphetm-POS* oxycodn-NEG mthdone-NEG
___ 07:47PM BLOOD %HbA1c-9.7* eAG-232*
___ 10:46AM BLOOD HIV Ab-NEG
___ 01:30PM BLOOD HCV VL-5.0*
DISCHARGE LABS:
===============
___ 07:37AM BLOOD WBC-7.1 RBC-4.06* Hgb-12.1* Hct-35.0*
MCV-86 MCH-29.8 MCHC-34.6 RDW-13.3 RDWSD-41.5 Plt ___
___ 10:46AM BLOOD Glucose-183* UreaN-7 Creat-0.7 Na-141
K-4.3 Cl-102 HCO3-28 AnGap-11
___ 10:46AM BLOOD ALT-105* AST-112* LD(LDH)-321* AlkPhos-73
TotBili-0.2
___ 10:46AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.1 Mg-1.5*
IMAGING:
===============
___ XR R Foot
FINDINGS:
- Soft tissue ulceration along the plantar aspect of the great
toe subjacent to the first IP joint is noted with adjacent soft
tissue swelling. No cortical destruction or periosteal new bone
formation is present. Erosion along the medial head of the
first proximal phalanx is unchanged. Mild degenerative changes
of the first MTP joint and midfoot are present. No concerning
lytic or sclerotic osseous abnormality. No radiopaque foreign
body or soft tissue calcification. No acute fracture or
dislocation.
IMPRESSION:
- Soft tissue ulceration along the plantar aspect of the great
toe at the level of the first IP joint without radiographic
evidence for osteomyelitis.
MICROBIOLOGY:
===============
BCx NGTD
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Glargine 35 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. LamoTRIgine Dose is Unknown PO BID
3. Buprenorphine-Naloxone Film (4mg-1mg) 1 FILM SL BID
Discharge Medications:
1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID
RX *buprenorphine-naloxone 8 mg-2 mg 1 film sublingually twice a
day Disp #*8 Film Refills:*0
2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal once may
repeat once Disp #*1 Package Refills:*12
3. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Novolog 4 Units Lunch
Novolog 4 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
RX *blood sugar diagnostic Please check blood sugar before
mealtimes and at bedtime QMEALS and QHS Disp #*50 Strip
Refills:*0
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 42 Units before BKFT; 42 Units before BED; Disp
#*30 Applicator Refills:*0
RX *blood-glucose meter 1 meter kit once a day Disp #*1 Kit
Refills:*0
RX *lancets Please check blood sugars with meals and before
bedtime QMEALS & QHS Disp #*100 Each Refills:*0
RX *insulin lispro 100 unit/mL AS DIR Per sliding scale QID Disp
#*30 Applicator Refills:*0
4. HELD- DULoxetine ___ 60 mg PO BID This medication was held.
Do not restart DULoxetine ___ ___ speaking with your primary
care doctor.
5. HELD- LaMICtal XR (lamoTRIgine) 50 mg oral DAILY This
medication was held. Do not restart LaMICtal XR until speaking
with your psychiatrist
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
#LUMBAR ABSCESSES
#RIGHT HALLUX CELLULITIS
SECONDARY DIAGNOSES:
=====================
#TYPE 1 DIABETES
#POLYSUBSTANCE USE DISORDER
#SCABIES
#HEPATITIS C
#TRANSAMINITIS
#DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with R great toe ulcer, drainage of pus// Eval for
e/o osteo
TECHNIQUE: Right foot, two views
COMPARISON: Right foot radiographs ___
FINDINGS:
Soft tissue ulceration along the plantar aspect of the great toe subjacent to
the first IP joint is noted with adjacent soft tissue swelling. No cortical
destruction or periosteal new bone formation is present. Erosion along the
medial head of the first proximal phalanx is unchanged. Mild degenerative
changes of the first MTP joint and midfoot are present. No concerning lytic
or sclerotic osseous abnormality. No radiopaque foreign body or soft tissue
calcification. No acute fracture or dislocation.
IMPRESSION:
Soft tissue ulceration along the plantar aspect of the great toe at the level
of the first IP joint without radiographic evidence for osteomyelitis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: B Foot pain, Wound eval
Diagnosed with Cellulitis of right toe
temperature: 98.7
heartrate: 95.0
resprate: 18.0
o2sat: 97.0
sbp: 125.0
dbp: 61.0
level of pain: 4
level of acuity: 3.0 | ___, unstably housed and recently incarcerated, with PMH of
uncontrolled T1DM, depression, and polysubstance use disorder
(active IV use) c/b untreated HCV, who presents with R toe
cellulitis and lumbar abscesses. He was completed his course of
antibiotics and underwent I&D x 2 of abscesses. Patient became
agitated while awaiting discharge ___ and left prior to
receiving discharge appointments, paperwork, or scripts. Will
attempt to fax scripts to his pharmacy and call to coordinate
appointments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Lactose
Attending: ___.
Chief Complaint:
rectal foreign body
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ w/h/o anal condyloma removal ___, anal fistulectomy ___,
presents after having a cylindrical object inserted into his
anus
three days ago that he was subsequently unable to retrieve. He
inserted the sexual toy into his anus on ___ morning during
consensual sex with a female. He attempted a fleets enema 2 days
PTA without success, just with a small amount of bloody stool.
He has not stooled since. +flatus. He complains of no
abdominal
pain, N/V, now.
Past Medical History:
Anal condylomata, anal fistula, anxiety, depression, h/o
substance abuse
Social History:
___
Family History:
NC
Physical Exam:
Physical examination upon admission: ___:
Vitals: 98.2 62 126/87 20 96%
Gen: Anxious, NAD
Resp: CTA
CV: RRR
Abd: S, NT/ND
Ext: No c/c/e
Rectal: palpable foreign body in rectum, no gross blood
Pertinent Results:
no lab work done
Medications on Admission:
Viagra 50', Wellbutrin 150'', Trazodone 100'
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO BID
2. Nicotine Patch 14 mg TD DAILY
3. Docusate Sodium 100 mg PO BID
hold for diarrhea
4. traZODONE 200 mg PO HS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
rectal foreign body
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Foreign body in rectum.
TECHNIQUE: AP and lateral views of the pelvis.
COMPARISON: None.
FINDINGS:
A cylindrical radiopaque density measuring approximately 12 cm long is noted
within the rectum, and corresponds to the known history of foreign body.
Imaged bowel gas pattern appears unremarkable. No acute osseous abnormalities
are seen, and there are no soft tissue calcifications. Multilevel
degenerative changes within the lumbar spine are worse at L4-5 with
intervertebral disc space narrowing, subchondral sclerosis and osteophyte
formation.
IMPRESSION:
Radiopaque foreign body within the rectum as described above.
Radiology Report
HISTORY: Removal of foreign body.
TECHNIQUE: Upright AP and lateral views of the pelvis.
COMPARISON: ___ at 17:12.
FINDINGS:
Previously noted cylindrical radiopaque foreign body has been removed. No
residual radiopaque foreign body is seen. Imaged bowel gas pattern appears
unremarkable. Please note that assessment for free air is limited as the
entire abdomen including the diaphragms was not encompassed on these views.
There are no acute osseous abnormalities.
IMPRESSION:
Removal of previously noted radiopaque foreign body. Assessment for free
intraperitoneal air is limited on these views, and dedicated supine and AP
views of the entire abdomen are suggested for further assessment, if this is
of clinical concern.
Radiology Report
INDICATION: ___ man status post removal of rectal foreign body, to
evaluate for free air.
COMPARISON: Pelvis radiograph ___
FINDINGS: There is no evidence of intra-abdominal free air. There is mild
gaseous distention of the colon. The bowel gas pattern is nonobstructive. A
few colonic air-fluid levels are noted, nonspecific. There is mild
dextroconvex curve of the lumbar spine.
IMPRESSION: No free air.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FOREIGN BODY
Diagnosed with FOREIGN BODY IN ANUS & RECTUM, FB ENTERING OTH ORIFICE
temperature: 98.2
heartrate: 62.0
resprate: 20.0
o2sat: 96.0
sbp: 126.0
dbp: 87.0
level of pain: 1
level of acuity: 3.0 | ___ year old gentleman admitted to the acute care service with a
foreign body in his rectum. Upon admission, an x-ray of the
abdomen was done which showed a radiopaque foreign body within
the rectum. There were no signs of perforation noted. The
foreign body was extracted from the patient's rectum at the
bedside using lube and abdominal wall counterpressure. The
foreign body was removed in its entirety and
the patient felt clinical relief after removal. Repeat
abdominal film showed no foreign body. The patient's vital
signs have been normal and he has resumed a regular diet. He
was discharged home on HD #2 with follow-up with his primary
care provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
colonoscopy ___
History of Present Illness:
Ms. ___ is a ___ female with a history of HCV/EtOH
cirrhosis decompensated by HE with multiple admissions this year
for confusion, varices (grade 1 varices x 2 on EGD ___,
ascites, recent colitis, depression, who presents with abdominal
pain, lactic acidosis, and tachycardia.
She noted that pain is most prominent in RUQ. She reports pain
is acute in onset with associated nausea and NBNB emesis ___
bouts ofe emesis, ___ loose BM since abd pain yesterday am). She
reports similar pain previously when she was admitted for
colitis recently. Subjective fever. Denies chest pain, shortness
of breath, diarrhea, hematochezia, melena, urinary symptoms.
In ED, initial VS were 98 123 178/81 18 100% ra. On exam, pt was
noted to be in mild discomfort, w/ tenderness to palpation in
RUQ, without rebound or guarding. Labs were significant for
normal WBC (83% neutrophils), Hgb 12.5, Plt 83, INR 1.7, HCO3
21, Lactate 5.5, AST 95, ALT 40, AP 121, TBili 2.5, DBili 1.0.
RUQ U/S showed cirrhosis with patent portal veins, no focal
hepatic mass.
Pt was given 2L NS, morphine 5mg x3, and zofran.
Of note, patient was admitted in ___ and ___ with
similar symptoms including abdominal pain and sinus tachycardia.
Her abdominal pain was worked up with CTA which showed no
obstruction or ischemia but had concern for infectious colitis
in the right colon. She was given cipro/flagyl during both
admissions. Her abdominal ultrasound was unremarkable. Stool
cultures were sent due to N/V and were negative and flex sig was
done without evidence of colitis.
Patient's sinus tachycardia was noted to be improved after
fluids.
On transfer, patients vitals were 98.3 112 145/74 16 97% RA. On
the floor patient reitereated that her emesis initiall had 2
drops of blood one first vomiting spell yesterday am, but last
___ vomiting spells had no blood. Reprots 2 X loose bm, no
diarrhea. She also reports not taking her lactulsoe for 1 week,
and taking miralax instead.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
- Chronic HCV and Alcoholic Cirrhosis (genotype 1): complicated
by ascites, encephalopathy, portal hypertensive gastropathy,
grade I varices (___)
- Hx of ETOH abuse
- Major depressive disorder: multiple psychiatric
hospitalizations and prior suicide attempts
- Rheumatoid vs osteoarthritis, not medicated
- Type II Diabetes Mellitus; not medically managed
- Prolapsed uterus s/p pessary, now removed
- Rectocele/cystocele
- Lateral epicondylitis
- VRE
Past surgical history:
cholecystectomy
Social History:
___
Family History:
Mother passed away from ETOH cirrhosis.
Father had lung ca with liver mets.
Daughter with depression.
Physical Exam:
ON ADMISSION
VS:T 98.4 BP 146/84 HR 125 RR 18 O2 100 RA
General: NAD, AAOX3
HEENT: slight peteciea indicative of resovled cough soft
palate, no active rhinorhhea or epistaxis, no buccal elsions,
tongue dry buccal gutters moist
Neck: no cervical lad, no thyromegaly
CV: RRR, S1 and S2 aucsuclteds over aortic, pulmonic, tricuspid
valves
Lungs: CTAB on anterior and posterior chest
Abdomen: No fluid wave, tender only to periumbilical and
suprapubic are (with volutnary guarding), no rebound tenderness
or involuntary guarding otherwise
GU: no foley in okace
GI: external hemorroids present with no active bleeding guaiaic
negative.
Ext: no peripheral cyanosis/clubbing/edema
Neuro: + asterixis. mini cog wnl (can recall at 0 and 3
minutes).
Skin: no new rashes
ON DISCHARGE
VS:T 98.6 BP 119/59 HR 99 RR 20 O2 100 RA
General: NAD, AAOX3
HEENT: No cervical lad, no rhinorhhea, no epistaxis, clear
oropharynx
Neck: no cervical lad, no thyromegaly
CV: RRR, S1 and S2 aucsuclteds over aortic, pulmonic, tricuspid
valves
Lungs: CTAB on anterior and posterior chest
Abdomen: No fluid wave, no tenderness with distraction with
deep palpation with stehtoscope, mild periumbilical with
palpation with hand
GU: no foley in place
Ext: no peripheral cyanosis/clubbing/edema
Neuro: + asterixis. mini cog negative (can recall 3 words)
Skin: no new rashes
Pertinent Results:
ON ADMISSION
___ 02:25AM ___ PTT-38.5* ___
___ 02:25AM PLT COUNT-83*#
___ 02:25AM NEUTS-81.0* LYMPHS-13.9* MONOS-4.7 EOS-0.2
BASOS-0.2
___ 02:25AM WBC-5.9# RBC-3.85* HGB-12.5 HCT-38.1 MCV-99*
MCH-32.5* MCHC-32.8 RDW-19.4*
___ 02:25AM ALBUMIN-3.5
___ 02:30AM LACTATE-5.5*
___ 05:50AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 05:50AM URINE GRANULAR-1* HYALINE-1*
MICROBIOLOGY
___ 1:58 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
__________________________________________________________
___ 5:59 am URINE Site: NOT SPECIFIED CHEM# ___
___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 2:25 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
2155.
GRAM POSITIVE ROD(S).
RADIOLOGY
CT ABD PELVIS ___
ABDOMEN:
The liver is diffusely nodular in contour, compatible with known
cirrhosis. A
tiny, subcentimeter hypodensity within the left hepatic lobe is
unchanged from
prior examination is too small the characterize. No focal
suspicious hepatic
lesion is identified. The portal venous system is patent, and
there is
persistent cannulization of the umbilical vein. There is no
evidence of
intrahepatic ductal dilation. The gallbladder is surgically
absent. The
extrahepatic common biliary duct measures up to 1.0 cm,
unchanged and within
postcholecystectomy limits. The pancreas and bilateral adrenal
glands are
normal. The spleen is mildly enlarged, measuring up to 12.1 cm.
The kidneys
enhance symmetrically and are without suspicious solid mass.
Multiple,
bilateral renal hypodensities measure up to 1.0 cm in size,
stable from the
prior examination and likely representing simple cysts.
The stomach is grossly unremarkable in appearance. Oral
contrast is seen
extending into the ascending colon. The small and large bowel
are normal in
caliber and without evidence of wall thickening. The appendix
is unremarkable
in appearance (2a: 46). There is no retroperitoneal
lymphadenopathy by CT size
criteria. Nonspecific soft tissue density is noted at the level
of the celiac
axis, unchanged from ___ and of questionable clinical
significance. There is
no free abdominal fluid or pneumoperitoneum. The aorta and iliac
branches
contain calcifications and are normal in course and caliber. The
celiac trunk
and SMA are grossly patent.
PELVIS:
The bladder, sigmoid colon, and rectum are grossly unremarkable.
There is no
pelvic side-wall or inguinal lymphadenopathy by CT size
criteria. No free
pelvic fluid is identified.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion
concerning for
malignancy.
IMPRESSION:
1. No evidence of small bowel obstruction, ileus, appendicitis,
or colitis to
explain the patient's symptoms.
2. Cirrhosis and recanalization of the umbilical vein,
unchanged from prior
examination.
colonoscopy ___
Impression: Polyp in the descending colon (polypectomy)
Given very tortuous and long colon, the cecum was unable to be
reached.
Medium-sized internal hemorrhoids.
Otherwise normal colonoscopy to ascending colon
Recommendations: - Will followup biopsy pathology report and
communicate results as they are available
- *Future colonoscopy to be done with adult colonoscope and MAC
anesthesia
- Given cecum was not reached, next interval colonoscopy to be
discussed and determined with primary Liver team
LAB RESULTS ON DISCHARGE
___ 06:55AM BLOOD WBC-2.7* RBC-2.90* Hgb-8.9* Hct-28.5*
MCV-98 MCH-30.7 MCHC-31.3 RDW-19.1* Plt Ct-58*
___ 02:25AM BLOOD Neuts-81.0* Lymphs-13.9* Monos-4.7
Eos-0.2 Baso-0.2
___ 06:55AM BLOOD Glucose-111* UreaN-11 Creat-1.0 Na-137
K-3.2* Cl-107 HCO3-28 AnGap-5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 60 mL PO TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. QUEtiapine extended-release 50 mg PO QAM
8. QUEtiapine extended-release 150 mg PO QPM
9. Rifaximin 550 mg PO BID
10. Sertraline 25 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 60 mL PO ___ TIMES DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. QUEtiapine extended-release 50 mg PO QAM
8. QUEtiapine extended-release 150 mg PO QPM
9. Rifaximin 550 mg PO BID
10. Spironolactone 25 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Ondansetron ___ mg PO Q8H:PRN nausea, vomiting
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours as
needed for pain Disp #*30 Tablet Refills:*0
14. OxycoDONE (Immediate Release) 2.5-7.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 - 1.5 tablet(s) by mouth every 4 hours
Disp #*18 Tablet Refills:*0
15. Outpatient Lab Work
ICD 280: Anemia
Please Draw CBC and ___
Fax to PCP
___
___
16. TraZODone 200 mg PO QHS
17. Sertraline 50 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY
19. pramipexole 0.125 mg oral qhs
20. Prochlorperazine 5 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Resolved Gastroenteritis
Functional abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with history of cirrhosis status post cholecystectomy with
right upper quadrant pain.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT of the abdomen and pelvis from ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. There is no focal
liver mass. The main portal, right anterior and posterior, and left portal
veins are patent with hepatopetal flow. There is no ascites. Of note, the
umbilical vein is patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 9 mm
and tapers near the pancreatic head.
GALLBLADDER: Gallbladder is surgically absent.
PANCREAS: The head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 7 cm.
KIDNEYS: Limited views of the right kidney demonstrate simple cysts with no
hydronephrosis.
IMPRESSION:
1. Cirrhosis with patent portal veins. No focal hepatic mass. No ascites.
2. Mild prominence of the CBD is within post cholecystectomy limits.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with hcv/etoh cirrosis, controlled hep enceph,
new abd pain // r/o ileus, colitis
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats.
DLP: 901.62 mGy-cm
COMPARISON: ___.
FINDINGS:
Linear atelectasis is noted at the left lung base.
ABDOMEN:
The liver is diffusely nodular in contour, compatible with known cirrhosis. A
tiny, subcentimeter hypodensity within the left hepatic lobe is unchanged from
prior examination is too small the characterize. No focal suspicious hepatic
lesion is identified. The portal venous system is patent, and there is
persistent cannulization of the umbilical vein. There is no evidence of
intrahepatic ductal dilation. The gallbladder is surgically absent. The
extrahepatic common biliary duct measures up to 1.0 cm, unchanged and within
postcholecystectomy limits. The pancreas and bilateral adrenal glands are
normal. The spleen is mildly enlarged, measuring up to 12.1 cm. The kidneys
enhance symmetrically and are without suspicious solid mass. Multiple,
bilateral renal hypodensities measure up to 1.0 cm in size, stable from the
prior examination and likely representing simple cysts.
The stomach is grossly unremarkable in appearance. Oral contrast is seen
extending into the ascending colon. The small and large bowel are normal in
caliber and without evidence of wall thickening. The appendix is unremarkable
in appearance (2a: 46). There is no retroperitoneal lymphadenopathy by CT size
criteria. Nonspecific soft tissue density is noted at the level of the celiac
axis, unchanged from ___ and of questionable clinical significance. There is
no free abdominal fluid or pneumoperitoneum. The aorta and iliac branches
contain calcifications and are normal in course and caliber. The celiac trunk
and SMA are grossly patent.
PELVIS:
The bladder, sigmoid colon, and rectum are grossly unremarkable. There is no
pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free
pelvic fluid is identified.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. No evidence of small bowel obstruction, ileus, appendicitis, or colitis to
explain the patient's symptoms.
2. Cirrhosis and recanalization of the umbilical vein, unchanged from prior
examination.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
CLINICAL HISTORY ___ year old woman with hcv/etoh cirrosis, abd pain, recent
emesis // r/o pna, acute path r/o pna, acute path
COMPARISON: ___
FINDINGS:
Streaky bibasilar density consistent with subsegmental atelectasis or scarring
persists. The lungs are otherwise clear. The heart is normal in size.
Mediastinal structures are otherwise unremarkable. The bony thorax is grossly
intact. There is no significant change.
IMPRESSION:
Bibasilar subsegmental atelectasis and or scarring.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: n/v/d, Abd pain
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.0
heartrate: 123.0
resprate: 18.0
o2sat: 100.0
sbp: 178.0
dbp: 81.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ female with a history of HCV/EtOH
cirrhosis decompensated by HE with multiple admissions this year
for confusion, varices (grade 1 varices x 2 on EGD ___,
ascites, depression, who presented with abdominal pain, lactic
acidosis, and tachycardia, and emesis.
BRIEF HOSPITAL COURSE
#Abdominal pain/emesis:
Patient was recently admitted multiple times for abdominal pain
and found to have colitis. No ascites were present on exam. CT
abdomen and pelvis on ___ showed no evidence of small bowel
obstruction, ileus, appendicitis, or colitis to explain the
patient's symptoms, and patient's emesis had completely resolved
upon admission. Given patient's recurrent admissions for
abdominal pain for presumed colitis, decision was made for
colonoscopy for definitive diagnosis. Patient had colonoscopy on
___ which showed no actiive inflammation, but one polyp
which was removed. As a result, patient was discharged with
diagnosis of presumed prior gastroenteritis given resolution of
symptoms on admission.
# Alcohol use: Patient is good historian and reported no recent
alcohol use (X 1.5 months). She has no signs of alcohol
withdrawal and was continued on her home thiamine and folate in
house.
# Lactic Acidosis: Elevated to 5.5 on admission, after fluid
improved to 1.7. Lactate elevation was determined to be due to
likely hypovoelmia in the setting of emesis which resolved on
hospital stay.
#Sinus tachycardia:
She has a known history of HR in the 100s during prior
admissions, now recurrent. After initial fluid resuscitation
(see above) HR stabilized.
# ETOH/HCV crrhosis: C/b ascites, encephalopathy (multiple
admissions this year for confusion), 2 grade 1 varices on EGD
___ and portal hypertensive gastropathy. HCV genotype 1. MELD
17 (similar to prior admissions). During this admission given
HCV history cryoglobins were checked (as possible etiology of
ischemic colitis to explain her abdominal pain) and were pending
at time of discharge.
# Hx HEPATIC ENCEPHALOPATHY: Positive hx in past, not on this
admission. Patient reported she has not taken her lactulose for
7 days, though she was not encephalopathic on admission. Her
home lactulose was restarted.
CHRONIC ISSUES
#Depression/psychosis: Patient was continued on her home
quetiapine.
#GERD: patient was coninued on her home omeprazole in house
TRANSITIONAL ISSUES
-Patient is being discharged on a very short course taper of
oxycodone for her abdominal pain. Please refrain from extending
course unless patient has severe, debilitating pain, due to
concern for constipation.
-Patient colonoscopy showed polyp which was removed; pathology
of polyp from ___ will need to be followed.
-cryoglobin studies pending at time of discharge (were drawn
initially before colonoscopy given history of HCV, and
possibility of vasculitic mediated colitis). Patient will follow
up with liver clinic as above
- After colonoscopy and polyp removal patient had related hgb
drop from 10.3 to 8.9 but was in stable condition, with iron
studies wnl. Patient given rx for CBC and Chem-10 draw on
___ with results to be faxed to PCP. Patient advised to
come in if she has any change in stool color or bleeding.
-On day of discharge patient had K of 3.2, Mg of 1.5. These were
repleted orally, but as above, patient given RX for chem-10 lab
draw prior to PCP ___ replete as needed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old M with cholangiocarcinoma s/p whipple in ___
followed by adjuvant chemo/radiation which completed in ___, ventral hernia s/p repair in ___ and inguinal hernia
s/p repair 2 weeks ago with acute on chronic abdominal pain,
nausea, and vomiting.
Pt reports nausea, vomiting and periumbilical abdominal pain
since ___ of this year. He has had 8lbs of weight loss in the
past two months. His appetite has been poor and he has felt
fatigued. However, in the past 3 days he says that his vomiting
has been multiple times per day, including in the ER where he
was noted to have bilious vomiting. This is an increase from
1/week vomiting he had prior. No blood in vomitus. Bowel
movements two days ago. Normal per report. He says that his
periumbilical abdominal pain has also worsened. ___ at the time
of interview. He has been taking oxcycodone and vicodin given to
him post operatively from his recent surgeries.
He presented to ___ and was sent to ___ ED.
There he had a CT which showed no obstruction. A fluid
collection was seen near the site of his recent hernia repair.
He was seen by surgery and admitted to the medical service for
___ care.
Past Medical History:
cholangiocarcinoma s/p whipple
s/p ventral hernia repair
s/p inguinal hernia repair
HTN
DM2
Social History:
___
Family History:
Father died from complications of DM1
Mother living but has hx breast cancer, bt mastectomies
Physical Exam:
On admission:
================
Vitals: 98.2 183/84 75 16 100%RA\
Gen: NAD, gaunt appearing
HEENT: moist mm, no scleral icterus
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: midline scar, no tenderness to palpation, soft,
nondistended, +bs; R inguinal surgical site with clean dressing
no erythema; no bulge or tenderness
Back: no cva tenderness
Ext: no edema
Neuro: alert and oriented x 3
On discharge:
================
Vitals: AF/98.2, 140s-170s/60s-70s, 60s-70s, ___, 100% on RA;
eating well
Gen: NAD, gaunt appearing
Eyes: EOMI, sclearae anicteric
HEENT: MMM, OP clear
CV: RRR, no MRG
Pulm: CTA ___
Abd: midline scar, no tenderness to palpation, soft,
nondistended, +BS; R inguinal surgical site with clean dressing
no erythema; no bulge or tenderness
Back: No cva tenderness. No kyphosis.
Ext: WWP, no edema, no rash, no arthritis
Neuro: AAOx3
GU: No foley
Pertinent Results:
ON ADMISSION:
================
___ 08:45PM GLUCOSE-111* UREA N-17 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-23 ANION GAP-13
___ 08:49PM LACTATE-0.9
___ 08:45PM LIPASE-6
___ 08:45PM ALT(SGPT)-31 AST(SGOT)-19 ALK PHOS-97 TOT
BILI-1.0
___ 08:45PM ALBUMIN-3.8 CALCIUM-9.0 PHOSPHATE-3.6
MAGNESIUM-1.7
___ 08:45PM WBC-5.4 RBC-3.72* HGB-10.8* HCT-31.1* MCV-83
MCH-29.1 MCHC-34.9 RDW-14.1
___ 08:45PM PLT COUNT-210
___ 08:45PM NEUTS-76.5* LYMPHS-16.6* MONOS-4.5 EOS-1.8
BASOS-0.7
CT Abdomen/Pelvis (prelim):
1. No evidence of obstruction. Patient is status post Whipple
with trace
pneumobilia noted within the liver. Additional trace amount of
free fluid is noted about the liver and tracking inferiorly
along the right pericolic gutter.
2. Right inguinal fluid and air filled rim enhancing structure
with overlying subcutaneous inflammatory changes, findings
concerning for an abscess.
AFTER ADMISSION:
================
CT Abdomen/Pelvis (final read ~12 hours after prelim read):
1. New or more extensive, difficult to compare given
differences in acquisition, soft tissue density extending from
the pancreatic head bed and extending posteriorly to the
retroperitoneum encasing the celiac and superior mesenteric
arteries as well as portal vein. This is concerning for
recurrent
tumor.
2. Patient is status post Whipple with trace pneumobilia noted
within the liver. Additional trace amount of free fluid is noted
about the liver and tracking inferiorly along the right
pericolic gutter, decreased since prior examination dated ___.
3. Right inguinal fluid and air filled structure with overlying
subcutaneous inflammatory changes may reflect postoperative
changes status post recent hernia repair with a residual seroma.
An abscess in the absence of pain at the site is felt unlikely.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Creon 12 2 CAP PO TID W/MEALS
4. Lorazepam 0.5 mg PO Q6H:PRN anxiety
5. Megestrol Acetate 400 mg PO DAILY
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
4. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN abdominal pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*84
Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*120 Tablet Refills:*3
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*180 Capsule Refills:*3
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*90 Packet Refills:*3
9. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice daily
Disp #*360 Tablet Refills:*3
10. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 8
hours Disp #*84 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
- Recurrent cholangiocarcinoma (most likely)
- Nausea with vomiting
- Periumbilical abdominal pain
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
INDICATION: ___ male with abdominal pain.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained after the administration of intravenous contrast. Coronal and
sagittal reformations were generated and reviewed.
DOSE: 388 mGy-cm.
COMPARISON: CT dated ___.
FINDINGS:
Chest: The bases of the lungs are clear bilaterally. Coronary artery
calcifications are noted. There is no pericardial effusion, resolved since
prior examination.
Abdomen: The liver appears homogeneous in attenuation. Patient is status post
Whipple procedure with hepaticojejunal anastomasis and expected trace
pneumobilia. Patient is status post cholecystectomy. The remaining portion of
the pancreas is unremarkable. There appears to be new or more extensive soft
tissue density extending from the pancreatic head bed posteriorly to the
retroperitoneum encasing the celiac axis, superior mesenteric artery, and
portal vein, concerning for recurrent tumor. The spleen is within the upper
limits of normal in size without focal lesions. Bilateral adrenal glands are
unremarkable. Kidneys enhance symmetrically, unremarkable in appearance. No
focal lesion is identified.
There is trace amount of fluid which surrounds the liver and descends along
the right pericolic gutter which appears to be of low density and decreased in
amount when compared to prior examination dated ___. Contrast is seen
within the stomach lumen. Contrast is identified distally within loops of
small bowel. There is no evidence of obstruction. The appendix is not well
visualized. Loops of large bowel demonstrate moderate fecal load and is
otherwise unremarkable. There is no free intra-abdominal air.
The abdominal aorta is normal in caliber without aneurysmal dilatation. There
is no retroperitoneal or mesenteric adenopathy.
Pelvis: The bladder is well distended, grossly unremarkable. The prostate
gland and seminal vesicles are within normal limits. Trace amount of pelvic
free fluid is noted. There is no inguinal or pelvic wall adenopathy. Within
the right inguinal canal, there is a 1.9 x 3.2 x 4.5 cm fluid-filled rim
enhancing structure with foci of air. This does not appear to be connected to
a loop of bowel and is concerning for a focal abscess. Surrounding
inflammatory changes are noted within the subcutaneous tissues anterior to
this structure. Patient is ___ weeks status post a right inguinal hernia
repair and these findings may represent postoperative changes with residual
seroma. There is no left-sided inguinal hernia. There is no inguinal or pelvic
sidewall adenopathy.
Osseous structures: No suspicious lytic or blastic lesions are identified.
Multilevel degenerative changes are identified most prominent at the L5-S1
level with disc space narrowing and endplate sclerosis.
IMPRESSION:
1. New or more extensive, difficult to compare given differences in
acquisition, soft tissue density extending from the pancreatic head bed and
extending posteriorly to the retroperitoneum encasing the celiac and superior
mesenteric arteries as well as portal vein. This is concerning for recurrent
tumor.
2. Patient is status post Whipple with trace pneumobilia noted within the
liver. Additional trace amount of free fluid is noted about the liver and
tracking inferiorly along the right pericolic gutter, decreased since prior
examination dated ___.
3. Right inguinal fluid and air filled structure with overlying subcutaneous
inflammatory changes may reflect postoperative changes status post recent
hernia repair with a residual seroma. An abscess in the absence of pain at
the site is felt unlikely.
NOTIFICATION: Updated impression regarding the apparent more extensive mass
extending from the pancreatic bed to the retroperitoneal is concerning for
recurrent tumor communicated after morning read out with the attending on ___ at 9:23 am to Dr. ___ page text after two failed attempts
to page for direct communication via telephone. A call was made to Dr.
___ listed covering the patient in POE, with the updated report
at 9:29 on ___.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with history of cholangiocarcinoma; restaging of
extrahepatic cholangiocarcinoma s/p Whipple procedure with new local
recurrence based on ab CT from ___.
TECHNIQUE: Contrast-enhanced chest CT was performed acquiring sequential
axial images from the thoracic inlet through the adrenal glands. Thin section
axial, coronal, sagittal and axial MIP's were also obtained. 75 cc of
Omnipaque 350 were administered intravenously without reported complication.
DOSE: Total DLP = 235.40mGy-cm
COMPARISON: No prior chest CT available for comparison.
FINDINGS:
The thyroid gland is unremarkable. There are no pathologically enlarged
supraclavicular, mediastinal, hilar or axillary lymph nodes.
Heart size is normal with no pericardial effusion. Scattered coronary artery
and mitral annular calcifications are present. The main pulmonary artery and
thoracic aorta are normal caliber. No incidental pulmonary embolism is
identified.
A few punctate pulmonary nodules measuring up to 1 mm are identified (5:105,
106, 116). A few punctate calcified granulomas are also present (5: 175, 205,
273). There is no endobronchial lesion or pleural effusion.
Mild bilateral gynecomastia is incidentally noted.
Multilevel spinal degenerative changes are stable. A sclerotic lesion
involving the T3 vertebral body is most consistent with a bone island.
For a detailed discussion of the upper abdomen, please refer to the separate
report from the CT abdomen/pelvis performed one day prior.
IMPRESSION:
A few punctate pulmonary nodules measuring up to 1 mm have a relatively low
index of suspicion for malignancy. However, given the known history of
diagnosis of cholangiocarcinoma, a three-month followup chest CT is
recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with NAUSEA WITH VOMITING
temperature: 99.1
heartrate: 81.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | ISSUES THIS HOSPITAL STAY
# Recurrent cholangiocarcinoma: Recurrence suggested by findings
on abdominal CT from admission.
# Abdominal pain, nausea, vomiting: Attributed to problem #1
above. Improved with conservative measures (oxycodone, zofran,
IVF). Advanced diet to regular on ___.
# Recent hernia repairs: Stable on imaging. Incisions CDI
without signs of hernia recurrence.
# Anemia: Hct remained at his outpatient baseline. Etiology
likely multifactorial (chronic blood loss, anemia of
inflammation, prior chemo).
# HTN: Hypertensive while here, but attributed to pain. He was
asymptomatic, so opted to observe, witholding directed treatment
as his pressures will likely improve as his disease progresses
or he undergoes chemotherapy.
# DM : Continued home Lantus and SSI.
NARRATIVE
___ with cholangiocarcinoma s/p Whipple and chemoradiation in
___, recent ventral and inguinal hernia repairs, who presented
with acute on chronic abdominal pain, nausea, vomiting. His
symptoms improved with conservative therapy (short course of
bowel rest, some IV fluids, PO oxycodone, and IV Zofran), and
his diet was advanced. His pain regimen was uptitrated; he was
placed on Oxycontin q12h for improved long term control, along
with oxycodone 5mg q4h as needed for breakthrough. He was also
put on a bowel regimen.
Unfortunately, his abdominal CT scan showed likely recurrence of
cancer. I discussed his case with the oncology fellow ___
___ and had email correspondence with Dr ___. He
underwent restaging chest CT, and outpatient followup was
arranged. A palliative care consult was also obtained this
admission, since he was not sure if he wanted to pursue
chemotherapy or focus only on symptoms. They made some
recommendations for pain management.
TRANSITIONAL
# Likely recurrent cancer: Has outpatient followup arranged.
# Code status: He was full code while here. Will need to be
discussed with primary providers as his goals of care change.
# Contact: ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / latex
Attending: ___
Chief Complaint:
fever, cough, nasal congestion, myalgia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with classical Hodgkin's
lymphoma now s/p 6 cycles of ABVD who is admitted with fever and
upper respiratory symptoms.
Patient reports that he began feeling ill day prior to
admission.
At first, he noticed stuffy nose and head congestion which
progressed to diffuse myalgias. Also has associated cough
productive of small amount of greenish sputum. He had a temp of
100.3 on day of admission, so he presented to the ED.
In the ED, initial VS were T 100.8, HR 97, BP 142/73, RR 18, O2
100%RA. Labs notable for WBC 14.6 (85%N), HCT 38.5, PLT 235, Na
139, K 4.1, HCO3 24, Cr 0.9, ALT 56, AST 32, ALP 60, TBIli 0.3,
negative UA. CXR was unremarkable. Patient was given 1g po
Tylenol, duonebs, vancomycin, zosyn, acyclovir, and 1L NS prior
to transfer for further manamgent. VS prior to transfer were T
98.7, HR 88, BP 135/77, RR 20, O2 97% RA.
No fevers or worsening symptoms overnight and since arrival.
ROS: Denies headache, dizziness, chest pain, hemoptysis,
abdominal pain. Had 1 episode of diarrhea yesterday but none
since then. No nausea, vomiting or constipation. No new rashes
or
lesions.
All other ROS negative.
Past Medical History:
PAST ONCOLOGIC HISTORY, per OMR:
He was in his usual state of health until four months ago, when
he developed drenching night sweats requiring changing his
pajamas and sheets. On self examination noticed soft lump in
left
supraclavicular area. He did some internet research and became
very concern that he may have lymphoma. He saw his PCP who
ordered chest CXR and sonogram of the nodules. The sonogram on
- ___ revealed pathologically enlarged LN and CXR on ___
showed possibly widened mediastinum that prompted CT chest on
- ___. The CT scan revlealed 4 x 2.5 CM left supraclavicular
mass, mass in anterior mediastinum 6.8 x 3.7 x 10.0 CM anterior
to innominate vein, another mass around 1 CM just above the main
pulmonary artery as well as 1.8 CM left hilar LN. He was
referred
to thoracic surgery for evaluation and ultimately underwent Left
supraclavicular lymph node biopsy on ___. the biopsy is
consistent with classical Hodgkin lymphoma.
- ___ C1D1 of AVD (B omitted due to BMBx results)
- ___ C1D15- ABVD, Bleomycin test dose and full dose
administered due to repeat BMBx results.
- ___: C2D1 ABVD (given bleomycin test dose # 2 and full
dose).
- ___: C2D15 ABVD (reduced dose of bleomycin as ordered due
to shortage of chemotherapy).
- ___: Repeat PFT's and restaging PET.
- ___: C3D1 ABVD (reduced dose bleomycin d/t shortage)
- ___: C3D15 ABVD (reduced dose bleomycin d/t shortage)
- ___: C4D1 ABVD (reduced dose bleomycin d/t shortage)
- ___: C4D15 ABVD (reduced dose bleomycin d/t shortage)
- ___ : C5D1 ABVD full dose
- ___: C5D15 AVD Bleomycin stopped due to possible pulmonary
toxicity
- ___: C6D1 AVD- Bleomycin omitted at last visit.
- ___ C6D15 AVD
PAST MEDICAL HISTORY:
- Hodgkin's lymphoma, as above
- Intermittent asthma
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.4 HR 138/64 BP 92 RR 18 SAT 97% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: Anicteric, PERLL, OP clear, MMM
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, soft inspiratory
wheeze
diffusely, otherwise clear to auscultation
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: 1cm tender subcuanteous nodule under right nipple
DISCHARGE PHYSICAL EXAM:
VS: Tm 100.4 ___ TC 98.6 124/86 75 18 97%RA
GEN: Pleasant, lying in bed comfortably
HEENT: Anicteric, PERLL, OP clear, MMM
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, soft inspiratory
wheeze
diffusely on RUL, otherwise clear to auscultation
ABD: Normal bowel sounds, soft, non-tender, non-distended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: 1cm tender subcutaneous nodule under right nipple
ACCESS: POC deaccessed at discharge
Pertinent Results:
___ 12:00AM GLUCOSE-139* UREA N-11 CREAT-0.9 SODIUM-136
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
___ 12:00AM ALT(SGPT)-49* AST(SGOT)-26 LD(LDH)-220 ALK
PHOS-54 TOT BILI-0.4
___ 12:00AM CALCIUM-8.9 PHOSPHATE-2.5* MAGNESIUM-2.0
___ 12:00AM WBC-11.7* RBC-4.10* HGB-11.8* HCT-35.9*
MCV-88 MCH-28.8 MCHC-32.9 RDW-14.7 RDWSD-47.3*
___ 12:00AM PLT COUNT-208
___ 10:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 09:15AM URINE HOURS-RANDOM
___ 09:15AM URINE UHOLD-HOLD
___ 09:15AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:43AM LACTATE-0.9
___ 04:35AM GLUCOSE-117* UREA N-15 CREAT-0.9 SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
___ 04:35AM estGFR-Using this
___ 04:35AM ALT(SGPT)-56* AST(SGOT)-32 ALK PHOS-60 TOT
BILI-0.3
___ 04:35AM WBC-14.6*# RBC-4.38* HGB-12.7* HCT-38.5*
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.1 RDWSD-45.5
___ 04:35AM NEUTS-84.7* LYMPHS-7.0* MONOS-6.4 EOS-1.0
BASOS-0.4 IM ___ AbsNeut-12.40*# AbsLymp-1.02*
AbsMono-0.93* AbsEos-0.15 AbsBaso-0.06
___ 04:35AM PLT COUNT-235
___ 04:35AM WBC-14.6* LYMPH-7* ABS LYMPH-1022 CD3-83
ABS CD3-853 CD4-38 ABS CD4-390 CD8-38 ABS CD8-383 CD4/CD8-0.99
___ 12:00AM BLOOD WBC-11.7* RBC-4.10* Hgb-11.8* Hct-35.9*
MCV-88 MCH-28.8 MCHC-32.9 RDW-14.7 RDWSD-47.3* Plt ___
___ 04:35AM BLOOD Neuts-84.7* Lymphs-7.0* Monos-6.4 Eos-1.0
Baso-0.4 Im ___ AbsNeut-12.40*# AbsLymp-1.02* AbsMono-0.93*
AbsEos-0.15 AbsBaso-0.06
___ 12:00AM BLOOD Glucose-139* UreaN-11 Creat-0.9 Na-136
K-3.5 Cl-99 HCO3-25 AnGap-16
___ 12:00AM BLOOD ALT-49* AST-26 LD(LDH)-220 AlkPhos-54
TotBili-0.4
___ 12:00AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.0
MICROBIOLOGY:
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-CANCELLED due to inadequate specimen
___ Repeat Respiratory viral screen PND
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
EMERGENCY WARD
IMAGING:
___ Imaging CHEST (PA & LAT)
A right chest port terminates in the low SVC. Lungs are clear.
There is no pneumothorax. The cardiomediastinal silhouette is
unremarkable. There is no pleural effusion.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with cancer, fever // ? infectious process
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
A right chest port terminates in the low SVC. Lungs are clear. There is no
pneumothorax. The cardiomediastinal silhouette is unremarkable. There is no
pleural effusion.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Shortness of breath
temperature: 100.8
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 142.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT AND PLAN: Mr. ___ is a ___ year old man with
classical Hodgkin's lymphoma now s/p 6 cycles of ABVD who is
admitted from the ED with fever.
#Fever/Leukocytosis: Patient with fever and leukocytosis with
apparent upper respiratory tract infection. Given diffuse
myalgias and single episode of diarrhea favor viral etiology
(although does have predominance of PMN's on leukocytosis).
Regardless, given lack of clear other bacterial source (negative
chest CXR, POC in good condition and no clear abdominal process)
and overall well appearance; will receive 7D course of
levofloxacin (___) per primary oncologist
-F/U blood, urine cultures, flu and respiratory screen.
-Tamiflu empirically given sick contacts but discontinued prior
to d/c
#Diarrhea: Had 1 episode yesterday evening and another episode
this evening. We will obtain stool for cultures for further
evaluation prior to d/c
#Hodgkin's Lymphoma: S/p 6 cycles ABVD. No FDG avid disease on
PET; some concern for 2 small residual masses on CT. Being
considered for adjuvant XRT. Continue acyclovir PPX
#Transaminitis, mild: not new and appears to be improving
steadily, likely chemotherapy-effect, continue to monitor and
trend
#Asthma: appears to be mildly exacerbated in the setting of
upper
respiratory symptoms, improvement with albuterol prn
ACCESS: POC
CODE: Full (presumed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: Wife, ___ ___
DISPO: discharged ___ with follow up on ___ with Dr.
___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending: ___.
Chief Complaint:
Left foot ulceration
Major Surgical or Invasive Procedure:
Debridement of left lateral foot
History of Present Illness:
Mr. ___ is a ___ with history of poorly controlled diabetes
with neuropathy, chronic kidney disease, recurrent foot
infections, hypertension and hyperlipidemia presenting with left
foot inflammation and tenderness for 5 days. 6 days ago, patient
saw his PCP for his right foot and his left foot was not
bothering him. About 5 days ago he started to notice some
erythema and a small blister forming ___ his left lateral foot.
He tried to drain it and describes some clear liquid and blood
coming out, but no puss. He began to feel burning pain ___ his
left foot the same night, but the pain has since subsided. Also
noticed warmth ___ his left foot up to his ankle. He denies
noticing any trauma to his left foot, and always wears shoes. He
has been feeling chills, night sweats and feverish
(non-objective) for the past week or so. Also felt some
decreased apetite ___ the last few days. Day prior to admission,
he noticed significantly increased sweeling, erythema, warmth
and clear/bloody drainage from his left foot. Other than this,
he relates chronic swelling ___ his right foot up to his calf and
pain ___ his right calf for which he takes ___ tyalonl/24hrs.
Denies current nausea, vomiting, dyspnea, chest pain. His blood
glucose levels are usually ___ the high 100s-200s, but ___ the
past few days were ___ the 300s.
___ the ED, initial vitals were 98.4 80 127/92 20 100%. Initial
labs showed WBC 13.3 w/ PMN 82.6%, HCT 30.9, Na 129, Cr 1.8.
Left foot and ankle xray did not show evidence of osteomyelitis.
He was started on vancomycin 1g IV and Ampicillin-Sulbactam 3g
IV. The left foot ulcer was debrided by podiatry showing
purulent drainage. Wound culture taken. Wet-to-dry dressing
placed. He was admitted for antibiotic treatment and surgical
debridement ___ the morning.
REVIEW OF SYSTEMS:
(+)per HPI+ vision changes ___ past few years, R testicle pain
for past few years.
(-) recent weight loss or gain, recent sleep changes, headache,
syncope, sinus tenderness, rhinorrhea, congestion, sore throat,
cough, palpitations, abdominal pain, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria, recent change
___ bowel or bladder habits, arthralgias or myalgias.
Past Medical History:
1. Diabetes ___: Diagnosed ___ ___, with neuropathy,
retinopathy, charcot foot (HgbA1c was 11.5 on ___
2. Recurrent foot infections
3. Hypertension: since ___
4. Dyslipidemia
5. Chronic Kidney Disease (baseline Cr: 1.5-1.8)
6. Anemia
7. Vitamin D deficiency
8. Osteopenia
9. Genital herpes
10. Hep B: hep B surface AB + (___)
11. Prostatitis
12. Colonic adenomas
13. Elevated PSA
Social History:
___
Family History:
Mother: ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.8, BP 100/66, HR 87, RR 18, O2 100/RA, wgt 226.4lbs
GENERAL: WD WN comfortable ___ NAD
HEENT: PERRL EOMI, sclera anicteric, slightly dry MM OP clear
NECK: supple, no LAD, no JVD, no thyromegaly
CARDIAC: RRR, S1, S2, no m/r/g
LUNG: CTAB no w/r/r
ABDOMEN: soft NT ND +BS no organomegally
GU: no foley
EXT: Chronic venous stasis skin changes, especially ___ right to
mid-calf. Diminished sensation bilat to mid-calf. Left foot
lateral superficial abscess. Left foot is diffusely warm and red
to mid calf. Right foot swollen, warm to mid-calf, healing ulcer
on R plantar toe. Decreased range of motion bilat ___ ankles and
toes.
2+ radial, ___, strength ___ BUE and BLE.
NEURO:
Mental Status: AAOx3
CN: II-XII intact
Motor: normal bulk, tone throughout. No adventitious mvmts, no
tremors or asterixis
Sensory: nml to light touch and vibratory sense ___ upper
extremity, diminished bilat ___ lower extremities to mid-calf
DISCHARGE PHYSICAL EXAM:
VS: T 98.3, BP 126/82 (SBP 114-147), HR 74, RR 14, O2 99/RA,
Gluc 375
notable for 2+ ___. Hyperpigmented skin changes on lower
legs. Left foot with large lateral 4cm ulceration. There are
deeper areas that cannot be probed to the bone. Right foot
swollen, healing ulcer on R plantar toe. No pain on palpation,
manipulation.
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-13.3*# RBC-3.73* Hgb-10.0* Hct-30.9*
MCV-83 MCH-26.9* MCHC-32.5 RDW-12.3 Plt ___
___ 03:45PM BLOOD Neuts-82.6* Lymphs-11.6* Monos-5.1
Eos-0.5 Baso-0.2
___ 03:45PM BLOOD Glucose-430* UreaN-29* Creat-1.8* Na-129*
K-4.1 Cl-92* HCO3-26 AnGap-15
___ 03:52PM BLOOD Lactate-1.9
___ 07:20AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.6
___ 07:20AM BLOOD ___ PTT-28.9 ___
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-7.3 RBC-3.83* Hgb-10.2* Hct-31.3*
MCV-82 MCH-26.6* MCHC-32.4 RDW-12.5 Plt ___
___ 07:45AM BLOOD ___ PTT-29.0 ___
___ 07:45AM BLOOD Glucose-344* UreaN-25* Creat-1.5* Na-134
K-5.2* Cl-96 HCO3-27 AnGap-16
___ 07:20AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.7
=======================================
MICROBIOLOGY:
___ ___ 4:27 pm SWAB Source: L foot ulcer.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE
IDENTIFICATION.
___________________
PROTEUS MIRABILIS
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS
BLOOD CULTURE ___: no growth (final)
=======================================
IMAGING:
___ FOOT AP,LAT & OBL LEFT
Soft tissue gas adjacent to the distal fifth metatarsal.
No
definite underlying cortical lucency or irregularity to suggest
acute
osteomyelitis radiographically. MRI is more sensitive for acute
osteomyelitis.
___ MRI left foot:
Findings concerning for early osteomyelitis within the distal
aspect of
the partially resected fifth metatarsal with prominent overlying
soft tissue ulceration. Prominent skin thickening with
subcutaneous edema extending over the dorsal aspect of the left
forefoot. Diffuse muscle edema and atrophy throughout the left
forefoot indicative of neuropathic changes.
=======================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL 2 TABS
DAILY
5. Viagra *NF* (sildenafil) 100 mg Oral ___ tab PRN sexual
activity
6. 70/30 40 Units Breakfast
70/30 35 Units Dinner
7. Felodipine 2.5 mg PO DAILY
8. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain
Discharge Medications:
1. Felodipine 2.5 mg PO DAILY
2. 70/30 40 Units Breakfast
70/30 35 Units Dinner
3. Simvastatin 40 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*42 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
7. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain
8. Aspirin 81 mg PO DAILY
9. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL 2 TABS
DAILY
10. Viagra *NF* (sildenafil) 100 mg Oral ___ tab PRN sexual
activity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Diabetic foot ulcer, early osteomyelitis
Secondary Diagnosis: Hyperglycemia and diabetes ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: New ulcer and infection of the left foot and lower leg. Evaluation
for osteomyelitis.
COMPARISON: Foot radiograph, ___.
THREE VIEWS OF THE LEFT FOOT: The phalanx of the fifth digit is absent.
There is soft tissue gas underlying the distal fifth metatarsal. There is no
underlying cortical lucency or irregularity suggestive of osteomyelitis.
There is osteophyte formation area around the navicular bone. No acute
fracture or dislocation is identified. A soft tissue defect likely
corresponds to the known ulcer.
THREE VIEWS OF THE LEFT ANKLE: There are mild degenerative changes including
osteophyte formation around the navicular bone. The ankle mortise is
preserved on this non-stressed view. There are no focal lytic or sclerotic
lesions.
IMPRESSION: Soft tissue gas adjacent to the distal fifth metatarsal. No
definite underlying cortical lucency or irregularity to suggest acute
osteomyelitis radiographically. MRI is more sensitive for acute
osteomyelitis.
Radiology Report
MR EXAMINATION OF THE LEFT FOOT WITH AND WITHOUT INTRAVENOUS CONTRAST
COMPARISON: Radiographs of the left foot performed ___.
TECHNIQUE:
Multisequence, multiplanar MR examination of the left forefoot was performed
both pre- and post-intravenous administration of gadolinium. A coronal T1 fat
sat post-contrast sequence was performed.
FINDINGS:
There is prominent skin ulceration along the plantar / lateral aspect of the
left forefoot extending to the distal head of the left fifth metatarsal which
measures approximately 2.7 cm AP x 2.5 cm TRV x 3.2 cm CC.
The patient is status post amputation of the left fifth toe as well as the
distal head of the left metatarsal (7:15). There is mild heterogeneous marrow
edema within the remaining distal portion of the left fifth metatarsal with
mild associated enhancement at this site. The T1-weighted images, however,
demonstrate residual intramedullary fat within the remaining portion of the
distal left fifth metatarsal.
The remaining imaged osseous structures demonstrate normal intramedullary fat
signal. There is no evidence of osteomyelitis within the remaining imaged
osseous structures.
There is apparent skin thickening with subcutaneous edema extending across the
dorsum of the left forefoot. There is apparent skin thickening over the
dorsomedial aspect of the left forefoot. There is however no MR evidence of
underlying osteomyelitis at this site. There is no drainable subcutaneous
fluid collection.
There is marked atrophy of the musculature of the left forefoot with
associated diffuse edema indicative of neuropathic change. The Lisfranc
ligament appears intact however somewhat heterogeneous in signal.
IMPRESSION:
1. Findings concerning for early osteomyelitis within the distal aspect of
the partially resected fifth metatarsal with prominent overlying soft tissue
ulceration.
2. Prominent skin thickening with subcutaneous edema extending over the
dorsal aspect of the left forefoot.
3. Diffuse muscle edema and atrophy throughout the left forefoot indicative
of neuropathic changes.
Findings were discussed via telephone with the covering clinical team at 8:30
am on ___.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: R FOOT PAIN
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF FOOT, CELLULITIS OF LEG
temperature: 98.4
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 127.0
dbp: 92.0
level of pain: 8
level of acuity: 3.0 | ___ with PMH uncontrolled IDDM, CKD, and recurrent foot
infections who presented with left foot inflammation and
tenderness for 5 days concerning for diabetic/venous ulcer vs
osteomyelitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Left knee pain
Major Surgical or Invasive Procedure:
Left knee washout and revision circlage-wire ORIF.
History of Present Illness:
___ yo man who underwent left MPFL reconstruction, lateral
release, and tibial tubercle plasty on ___ for left
knee wound I&D and VAC placement, and on ___ for I&D and
wound closure, now presenting with 1 day of worsening left knee
pain, swelling, and wound discharge. Patient was discharged on
___ on vanco BID after his culture grew Staph aureus.
Past Medical History:
Hypertension
Asthma
Morbid obesity
post-revision right subtalar joint fusion with tibial bone
graft,
___ - patellofemoral osteoarthritis
depression
Social History:
___
Family History:
Mother with CVA, sister with valvular heart disease
Physical Exam:
AFVSS
LLE
Incision c/d/i, w/o drainage
___
SILT ___
wwp +2dp
Pertinent Results:
___ 02:00PM ___ PTT-41.4* ___
___ 01:08PM URINE HOURS-RANDOM
___ 01:08PM URINE HOURS-RANDOM
___ 01:08PM URINE UHOLD-HOLD
___ 01:08PM URINE GR HOLD-HOLD
___ 01:08PM URINE COLOR-ORANGE APPEAR-Hazy SP ___
___ 01:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-5.5
LEUK-NEG
___ 01:08PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 01:08PM URINE AMORPH-RARE
___ 01:08PM URINE MUCOUS-OCC
___ 08:55AM GLUCOSE-86 UREA N-13 CREAT-1.0 SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 08:55AM estGFR-Using this
___ 08:55AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.3
___ 08:55AM WBC-6.4 RBC-3.92* HGB-12.2* HCT-36.7* MCV-94
MCH-31.2 MCHC-33.3 RDW-12.0
___ 08:55AM NEUTS-66.8 ___ MONOS-6.6 EOS-2.9
BASOS-0.7
___ 08:55AM PLT COUNT-266
Medications on Admission:
1. Rifampin 450 mg PO Q12H
2. Senna 8.6 mg PO BID
3. Aspirin 325 mg PO DAILY Duration: 14 Days
Cont for 14 days following discharge.
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Daptomycin 750 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 750 mg IV daily Disp #*42 Vial
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Rifampin 450 mg PO Q12H
4. Senna 8.6 mg PO BID
5. Aspirin 325 mg PO DAILY Duration: 14 Days
Cont for 14 days following discharge.
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left knee wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with recent picc line placement // verification
of picc line placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___
FINDINGS:
Hazy bibasilar opacities as on prior likely due to atelectasis. Elsewhere the
lungs are clear. Right PICC is seen with tip overlying the upper SVC.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Right PICC tip overlying the upper SVC.
Radiology Report
INDICATION: ___ with left knee swelling, previous septic arthritis //
Osteomyelitis,
TECHNIQUE: AP, lateral, and oblique views of the left knee.
COMPARISON: ___.
FINDINGS:
Postoperative changes at tibial tubercle transfer are again seen with hardware
unchanged in position since prior. There is no periprosthetic lucency. There
is no region of osteolysis. Postprocedure changes also seen in the distal
femur and patella. Ossific density just inferior to the patella is unchanged.
Diffuse soft tissue swelling is seen and there is a small suprapatellar
effusion.
IMPRESSION:
No significant change since ___ with postoperative changes as detailed
above. Small suprapatellar effusion. No radiographic evidence of
osteomyelitis.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old man s/p L knee washout and revision ORIF // s/p L
knee washout and revision ORIF
TECHNIQUE: Left knee,2 views
COMPARISON: Radiographs of the left knee ___.
FINDINGS:
There are skin staples and a drain overlying the anterior soft tissues. There
is redemonstration of two partially threaded screws and cerclage wires through
proximal tibial tubercle, status post tibial tubercle transfer, in good
alignment. There is no hardware fracture or loosening. There is no region of
osteolysis. No fracture, dislocation, or gross degenerative change is
detected. No focal lytic or sclerotic lesion is identified. There is an
inferior patellar pole enthesophyte. There is a suprapatellar joint effusion.
IMPRESSION:
Postoperative changes status post revision ORIF/tibial tubercle transfer in
good alignment. No evidence of hardware complication or osteomyelitis.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with redness, swelling, and tenderness in RUE.
PICC in place. // Please eval for clot.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in bilateral subclavian veins.
The right internal jugular and axillary veins are patent and compressible with
transducer pressure.
The right brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation. A PICC is
visualized within the basilic vein.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: WOUND EVAL LEFT KNEE
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, HYPERTENSION NOS
temperature: 98.6
heartrate: 79.0
resprate: 16.0
o2sat: 97.0
sbp: 125.0
dbp: 64.0
level of pain: 9
level of acuity: 3.0 | Patient presented with 1 day of worsening left knee pain,
swelling, and wound discharge. Patient was discharged on ___ on
vanco BID after his culture grew Staph aureus and returned to
the ED on ___ with complaints of pain and concern for
reinfection and was admitted. He was taken to the OR on ___ for
another washout and closure. He was also started on Daptomycin.
He was placed in a straight leg cylinder cast post operatively
and given instructions to follow up in clinic in 2 weeks and
with his scheduled infectious disease appointments. On ___ he
began to express pain at ___ site and recieved a RUE US which
negative for clot. The patient met criteria for discharge and
was sent home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ativan / Vicodin / Doxycycline / Codeine / lisinopril
Attending: ___.
Chief Complaint:
Bilateral lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of HTN, stable LUL nodule, and
s/p R THA in ___ (s/p revision by Dr. ___ on ___, now
presnting with bilateral lower extremity edema.
Pt underwent R hip THR on ___ for DJD. He was subsequently
involved in an accident in ___, whereby he was hit with a
revolving door. At the time, pt fell directly on his right side,
developed a squeaking noise and a discomfort at the prosthesis.
Pt had progressively bothersome ceramic squeaking, which
prompted him to undergo surgical revision on ___. Patient was
discharged home on ___ at which time HCTZ and irbesartan
were to be held for HoTN. Pt continued to hold these meds on
discharge.
Since discharge, pt had pain at the post-operative site. Pain
can be as severe as ___, but is currently ___ in severity. 2d
prior he noticed a brief episode of LLE (non-operative leg)
numbness, which resolved spontaneously. 1d prior to admission,
patient noted onset of lower extremity edema, R>L. This swelling
has since progressed. Pt also notes testicular swelling,
subjective fever to 100.6, and urinary retention. In addition he
has a mild headache.
Pt initially presented to ___. There he was found to have VS: T
97.6, BP 96/52, P 75, R 18, O2 Sat 96%RA. Labs there were
significant for Na 134, Cr 1.27, HCT 24.4. Pt received 500cc NS
and oxycodone 10mg prior to transfer to ___, for continuity of
Orthopedic care.
Of note, shortly after his ___ hospitalization for THR, pt
developed RLE edema, fever and AMS. AMS was attributed to
delerium and resolved spontaneously. Infectious source was not
identified.
In the ED intial vitals were: T 98.4 (Tm 101.6), P 80 BP 123/56
R 15 O2 Sat 98% on 2L. Per orthopedic surgery evaluation, there
was no evidence of wound infection. Labs were significant for
HCT 26.3, PLT 139, lactate 1.3, UA negative. CTA chest was
limited by motion but showed no evidence of a central pulmonary
embolism to the segmental level. There were small bilateral
pleural effusions and subsegmental atelectasis. The right
subclavian artery has a separate origin from the aortic arch and
coursed behind the esophagus, a normal variant. There was a
blind-ending tubular structure, origin dating from the
mediastinum and terminating in the left upper lobe has been
present since ___, and was thought to be likely congenital.
CXR showed trace b/l effusions, linear RLL opacity, suggestive
of atelectasis, and low lung volumes. ___ showed no evidence
of DVT within the lower extremities, although the right peroneal
veins were not visualized. Pt received furosemide 20mg IV x 1,
vanc 1g IV x 1, acetaminophen, oxycodone 5mg po x 2 and
lidocaine jelly. He was written for CTX but did not receive this
medication per MAR.
On the floor, pt reports feeling R hip pain but is otherwise at
baseline.
Review of Systems:
(+) + pruritis; pt reports having gained 25lbs in several weeks
(-) chills, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria, rash.
Past Medical History:
- HTN
- LUL lung nodule (stable)
- GERD
- Depression
- History of psychotic reaction during post-operative
hospitalization
- s/p L5-S1 laminectomy and fusion, epidural mass excision
- Osteoarthritis
- s/p R total hip replacement on ___ and s/p revision on
___
Social History:
___
Family History:
CAD in multiple family members.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - T: 97.9 BP: 124/57 HR: 78 RR: 20 02 sat: 94%RA
GENERAL: NAD, A+Ox3 but with some evidence of inattention
(multiple incorrect answers for year prior to correct answer)
HEENT: ATNC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, no sinus tenderness,
nontender supple neck, no LAD, no JVD; +facial flushing
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: Proximal/lateral RLE with large well-healing
incision. Staples in place; no erythema or discharge. +TTP. 2+
pitting edema bl; R>L
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in distal ___, unable to
assess strength in proximal RLE ___ pain. Sensation intact and
symmetric bilaterally.
SKIN: warm and well perfused, small erythematous lesions on
anterior chest. Pt reports pruritis and has some excoriations.
RECTUM: Slightly enlarged prostate without tenderness; no stool
in vault
DISCHARGE PHYSICAL EXAM
=======================
VS Tm 98.6 125/59 76 18 95% ___
GEN: middle aged man sitting at edge of bed in NAD
CV: No JVD, RRR, no m/r/g
PULM: clear bilaterally
ABD: soft, non-tender, non-distended
EXT: R hip with bandage and mild surrounding erythema. 2+ edema
in RLE to hip with some erythema/warmth; non-tender. LLE without
edema.
GU: no scrotal edema
NEURO: alert and oriented, intact attention, cranial nerves
intact to confrontation, normal motor exam though antalgic R hip
flexion/extension
Pertinent Results:
ADMISSION LABS
--------------
___ 06:12PM BLOOD WBC-7.1 RBC-2.92* Hgb-8.3* Hct-26.3*
MCV-90 MCH-28.5 MCHC-31.7 RDW-13.9 Plt ___
___ 06:12PM BLOOD Neuts-70.7* ___ Monos-8.4 Eos-2.3
Baso-0.3
___ 06:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Burr-1+ Tear Dr-1+ Acantho-OCCASIONAL
___ 06:12PM BLOOD ___ PTT-65.1* ___
___ 06:12PM BLOOD Glucose-113* UreaN-20 Creat-1.2 Na-136
K-4.7 Cl-102 HCO3-22 AnGap-17
___ 06:12PM BLOOD ALT-14 AST-32 LD(LDH)-138 AlkPhos-68
Amylase-33 TotBili-0.5
___ 06:12PM BLOOD proBNP-862*
___ 06:12PM BLOOD Lipase-17
___ 06:12PM BLOOD Albumin-3.3*
___ 06:35AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.3*
PERTINENT RESULTS
-----------------
___ 06:12PM BLOOD proBNP-862*
___ 06:12PM BLOOD Lipase-17
___ 06:12PM BLOOD Hapto-208*
___ 06:12PM BLOOD TSH-6.4*
___ 06:12PM BLOOD Free T4-1.1
___ 06:35AM BLOOD CRP-91.2*
DISCHARGE LABS
--------------
___ 07:20AM BLOOD WBC-6.2 RBC-2.69* Hgb-7.6* Hct-24.1*
MCV-90 MCH-28.1 MCHC-31.4 RDW-14.6 Plt ___
___ 07:20AM BLOOD Glucose-104* UreaN-24* Creat-1.5* Na-136
K-4.7 Cl-101 HCO3-22 AnGap-18
IMAGING
-------
___ LOWER EXTREMITY US W/ DOPPLER:
IMPRESSION: No evidence of DVT within the lower extremities,
although the right peroneal veins were not visualized.
___ CTA: 1. Interval development of small bilateral
non-hemorrhagic pleural effusions and adjacent subsegmental
atelectasis. Ground glass opacities could reflect expiratory
phase of imaging although some degree of edema is possible.
2. A blind-ending tubular structure extending from the
mediastinum to the left upper lobe is of unclear etiology, but
has not significantly changed since ___ and likely represents a
congenital process such as an atretic supernumerary bronchus
with mucoid impaction.
3. No evidence of pulmonary embolism to the segmental level.
Subsegmental arteries are difficult to evaluate due to motion
artifact.
___ TTE: IMPRESSION: Normal global and regional biventricular
systolic function. No diastolic dysfunction, pulmonary
hypertension or pathologic valvular abnormality seen.
___ CT R LEG:
IMPRESSION:
1. Probable subcutaneous seroma deep to the lateral right thigh
skin staples. Allowing for this, no hematoma or rim-enhancing
fluid collection.
2. No fracture or evidence of hardware complication.
3. Extensive subcutaneous edema throughout the thigh. Moderate
left knee
joint effusion.
MICRO
-----
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Avapro (irbesartan) 150 mg oral daily
3. Cyanocobalamin 1000 mcg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Diazepam 5 mg PO HS:PRN insomina
10. Acetaminophen 1000 mg PO Q8H
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 40 mg SC DAILY
13. Senna 8.6 mg PO BID
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Diazepam 5 mg PO HS:PRN insomina
5. Docusate Sodium 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Senna 8.6 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
12. Enoxaparin Sodium 40 mg SC DAILY Duration: 3 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
day ___ = ___ continued for 1 month
13. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 gram by mouth daily
as needed Disp #*15 Packet Refills:*0
14. Outpatient Lab Work
Chem7 and CBC to be drawn ___ or ___.
Fax results to PCP: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Status post right total hip arthroplasty
#Anemia
#Thrombocytopenia
#Hypertension
#Lower extremity edema
#Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right hip revision on ___, now with edema, warmth, and
hematocrit drop. Evaluate for abscess or hematoma.
COMPARISON: Radiographs ___.
TECHNIQUE: MDCT axial images were acquired through the right hip and femur
after administration of Omnipaque intravenous contrast. Bone reconstructions
and coronal and sagittal reformations are provided for review.
DLP: 1209.78 mGy-cm.
RIGHT FEMUR WITH INTRAVENOUS CONTRAST:
The study is limited by streak artifact from the hip arthroplasty. The
patient is status post right total hip arthroplasty. There is no evidence of
hardware loosening or complication. No periprosthetic fracture is seen. A
subchondral cyst in the superior acetabulum (401B:52) has been present since
at least ___. Skin staples are in place. Blood products are seen within
the gluteus muscles, but there is no discrete large hematoma.Probable
subcutaneous seroma deep to the skin staples measuring roughly 2.8 x 3.6
(axial) x 10 cm (3:53, 201b:60). Otherwise, no rim-enhancing fluid
collection is seen.
There is marked subcutaneous edema throughout the thigh extending to the level
of the knee, and possibly more inferiorly, although not imaged. There is a
moderate knee joint effusion. Amorphous calcifications at the right hamstring
tendons adjacent to the ischial tuberosity may represent heterotopic
ossification. Hard and soft atherosclerotic plaque is seen at the left distal
SFA and popliteal artery.
Evaluation of the intra-abdominal contents is limited, but demonstrates a
right inguinal hernia containing fluid. Air in the bladder is likely related
to recent instrumentation. Scattered diverticula are noted.
IMPRESSION:
1. Probable subcutaneous seroma deep to the lateral right thigh skin staples.
Allowing for this, no hematoma or rim-enhancing fluid collection.
2. No fracture or evidence of hardware complication.
3. Extensive subcutaneous edema throughout the thigh. Moderate left knee
joint effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEG SWELLING
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS
temperature: 98.4
heartrate: 80.0
resprate: 15.0
o2sat: 98.0
sbp: 123.0
dbp: 56.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ is a ___ with a PMHx of HTN, stable LUL nodule, and
sp R THA in ___ sp revision by Dr. ___ ___ now presnting
with bilateral lower extremity swelling and fever.
# Bilateral ___ Edema:
Unclear etiology why edema was bilateral. Possibly secondary to
holding HCTZ at last discharge. Left leg edema resolved with
Lasix x 2. Right lower extremitiy edema remained and was
attributed to soft tissue inflammation causing impaired venous
drainage of the limb. He had normal lower extremity Doppler US,
normal TTE, normal albumin, normal liver function, relatively
normal renal function without proteinuria. Cellulitis was felt
to be unlikely given absent cutaneous pain, no leukocytosis.
# Fever: Tm 101.6 in ER on POD#5. There was never an associated
leukocytosis or sepsis physiology. The fevers were attributed to
post-op inflammation versus drug fever - seen occasionally with
enoxaparin. There was no evidence of venous thromboembolism,
UTI, diarrhea, PNA, prostate tenderness, sinusitis, or LFT
abnormalities. Cellulitis and prosthetic joint infection were
felt to be unlikely and the patient was treated with only 2
doses of vancomycin. He was not discharged on antibiotics.
# Acute kidney injury: His Cr was rising at discharge (1.5 from
1.1 on admission). This was felt to be related to IV contrast
exposure ___ and ___. This elevation fit with the timeline of
contrast-induced nephropathy. He had no evidence of RP
hemorrhage on ___ CT to indicate ureteral compression and he
did not appear hypovolemic. At discharge, a follow up plan was
made for repeat chem7 to be drawn at PCP's office.
# Thrombocytopenia: RESOLVED. Has a history of recurrent
thrombocytopenia. 4T score for most recent admission is 2. Two
of three prior PLT count decreases that were associated with
heparin administration were also associated with fall of HCT
(i.e. blood loss in setting of surgery; pt received lovenox on
___ and ___ and had anemia both times in setting of
surgery). DDx includes alcohol related (given hx of etoh use per
record), consumption from ongoing mild bleeding associated with
surgery. Hemolysis unlikely based on LDH, haptoglobin, and
bilirubin. Thrombocytopenia resolved to normal during the
admission.
# Anemia: Likely ___ post-operative blood loss. Stable from
recent admission. Baseline Hgb >14, but here Hgb was ___.
Hemolysis labs were negative. Likely loss secondary to surgery
into hip, but there was no evidence of significant hematoma on
CT ___. We recommended repeat CBC as an outpatient in the next
___ days post-discharge.
# Right total hip arthroplast: ___. Weight bearing as tolerated
bilaterally. Saw physical therapy who recommended continuing
home ___.
# Constipation: Likely secondary to home opiates. He was treated
with an aggressive bowel regimen. He was discharged with stool
softeners.
# EtOH Use: Significant historical use per wife. None recently.
He did not display signs of alcohol withdrawal. He was given
folate, thiamine, B12, and a multivitamin.
# HTN: Held HCTZ and irbersartan (held after discharge from
arthroplasty). Normotensive here. Defer to PCP to restart when
renal function normalized and hypertension requires
reinitiation.
# GERD: Continued omeprazole
# Emergency Contact: ___ (wife): ___
# CODE STATUS THIS ADMISSION: FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___ with portal vein thrombosis, portal
hypertension secondary to schistosomiasis, previous variceal
bleed, likely cirrhosis, and splenectomy.
She has had abdominal pain for 2 days. It is constant but
improves with pain control. It radiates from her epigastrium
into her back. She has not identified any provoking or
palliating factors. She says the last time she had similar
symptoms was when she had variceal bleeding. She denies any
black or bloody stools; she reports that her stool is yellow.
She has had nausea but denies vomiting or hematemesis. She
denies dysuria. She has had a fever for several days, up to
102.
She was transferred to ___, where she had a CTA of her
chest which was unremarkable. Per radiology, there are varices
visible on the CTA but no active extravasation.
No stool in the vault. Denies melena.
In the ED, initial vital signs were:
100.1 114 117/72 18 98% RA
Labs notable for:
WBC 11, Hgb 6.5, Plt 493
INR 1.2
UA with 10 WBCs, few bacteria
She received IV morphine, octreotide/pantoprazole,
ceftriaxone/flagyl, and was not transfused prior to transfer.
Vitals prior to transfer to MICU: 100.6 114 106/65 21 100% RA
CT abd/pelvis without contrast were ordered and showed acute SMV
thrombus.
On arrival to the MICU, she says her pain is better.
Review of systems:
Complete ROS obtained and is otherwise negative.
Past Medical History:
- schistosomiasis c/b chronic PVT, ? report of portocaval shunt
- h/o splenectomy at age ___, pneumovax last ___
- GERD
- s/p c-sections
- h/o cholelithiasis
Social History:
___
Family History:
no liver disorders
Physical Exam:
ADMISSION EXAM
Vitals: t 100.6 bP 98/59 HR 107 Pox 100
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: RUQ tenderness
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: spider angiomas on chest
NEURO: no asterixis
DISCHARGE EXAM
VS: Tmax 98.8 BP 90-110/50-70s HR 80-90s RR 18 ___ on RA
GENERAL: NAD. Comfortable
Eyes: Anicteric sclera without conjunctival injection
ENT: MMM. No oral lesions
___: RRR, no m/r/g
LUNGS: CTAB, no w/r/c
ABDOMEN: soft, nondistended. No tenderness to palpation. No
rebound or guarding.
EXT: well perfused, no edema
NEURO: AOx3, no asterixis
Pertinent Results:
ADMISSION LABS
==============
___ 05:54AM BLOOD WBC-11.0*# RBC-2.86*# Hgb-6.5*#
Hct-21.7*# MCV-76*# MCH-22.7*# MCHC-30.0* RDW-21.1* RDWSD-55.8*
Plt ___
___ 05:54AM BLOOD ___ PTT-27.4 ___
___ 05:54AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-136
K-6.2* Cl-101 HCO3-16* AnGap-25*
___ 05:54AM BLOOD ALT-81* AST-158* LD(LDH)-901*
AlkPhos-124* TotBili-0.6
___ 10:35AM BLOOD Lipase-25
___ 05:54AM BLOOD Lipase-34
___ 06:00AM BLOOD cTropnT-<0.01
___ 05:54AM BLOOD cTropnT-<0.01
___ 10:35AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 Iron-PND
___ 05:54AM BLOOD Hapto-231*
___ 09:55AM BLOOD K-4.0
___ 05:58AM BLOOD Lactate-1.2
MICRO
=====
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
IMAGING
=======
CT abd/pelvis ___
1. No retroperitoneal hematoma.
2. The SMV appears enlarged compared with prior and slightly
hyperdense, with
surrounding fat stranding, concerning for acute SMV thrombosis.
3. Trace free fluid in the pelvis.
CTA abd/pelvis ___
IMPRESSION:
1. SMV and medial splenic vein thrombosis, both vessels are
expanded with
central filling defect, suggesting acute to subacute to
thrombus. There is mild mesenteric stranding and small volume
fluid. Single small bowel loop is mildly dilated, has normal
wall enhancement, consider follow-up serial radiographs to
exclude progressive dilatation. Mild wall thickening of the
ascending, transverse, descending ___ be reactive,
infectious, inflammatory or ischemic colitis should be
considered.
3. Findings of hepatic cirrhosis. No focal enhancing liver
lesion is
identified.
4. Chronic thrombosis of the portal vein with cavernous
transformation of
multiple collaterals at the hepatic hilum.
DISCHARGE LABS
==============
___ 06:13AM BLOOD WBC-6.6 RBC-4.02 Hgb-9.4* Hct-30.5*
MCV-76* MCH-23.4* MCHC-30.8* RDW-21.0* RDWSD-57.1* Plt ___
___ 06:13AM BLOOD Plt ___
___ 06:13AM BLOOD ___ PTT-32.4 ___
___ 06:13AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-136
K-5.3* Cl-100 HCO3-24 AnGap-17
___ 06:13AM BLOOD ALT-91* AST-121* AlkPhos-173* TotBili-0.4
___ 06:13AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 40 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subQ q12hr Disp #*60 Syringe
Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Nadolol 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Symptomatic anemia
Secondary:
Superior mesenteric vein thrombus
Cirrhosis
Schistosomiasis
s/p Splenectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ with abd pain, severe anemiaNO_PO contrast // RP bleed?
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: total DLP (Body) = 725 mGy-cm.
COMPARISON: MRI liver on ___, CT abdomen on ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Macronodular contour of the liver is stable in appearance.
The liver demonstrates homogeneous attenuation throughout. There is no
evidence of focal lesions within the limitations of an unenhanced scan. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is stranding around the pancreatic head
and extending along the course of the SMV.
SPLEEN: The spleen is surgically absent. Splenosis measuring 3.7 cm in the
left upper quadrant is unchanged.
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. Contrast is seen in the bilateral collecting systems related to
CTA performed earlier on same date.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. The colon and rectum are within
normal limits. The appendix is normal. There is no evidence of
retroperitoneal hematoma.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
trace simple free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. There are perigastric varices. The SMV appears enlarged compared
with prior, and slightly hyperdense, with surrounding fat stranding,
concerning for acute SMV thrombosis (2:34, 602b:33).
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 retroperitoneal hematoma.
2. The SMV appears enlarged compared with prior and slightly hyperdense, with
surrounding fat stranding, concerning for acute SMV thrombosis.
3. Fat stranding adjacent to the pancreatic head and extending along the SMV
is likely related to the process in the SMV, correlate with labs to exclude
pancreatitis.
4. Trace free fluid in the pelvis.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old woman with history of cirrhosis secondary tissue
system schistosomiasis, PV thrombus, possible new ___ thrombus, abdominal pain
// CT arterial and venous phase of A/P to better assess possible new SMV
thrombus, known portal vein thrombus, and look for mesenteric ischemia
post splenectomy.
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 5.2 s, 57.5 cm; CTDIvol = 4.3 mGy (Body) DLP = 248.5
mGy-cm.
2) Spiral Acquisition 7.1 s, 55.8 cm; CTDIvol = 16.2 mGy (Body) DLP = 902.0
mGy-cm.
Total DLP (Body) = 1,151 mGy-cm.
COMPARISON: CT abdomen pelvis without contrast from ___, MRI of
liver ___, CT abdomen pelvis from ___.
FINDINGS:
VASCULAR: There is chronic thrombosis of the main portal vein, with cavernous
transformation of multiple collaterals at the hepatic hilum. The SMV is
thrombosed with a small amount of adjacent mesenteric fat stranding. SMV
thrombosis is more extensive compared with ___, which is the most
recent comparison CT evaluated this vasculature with the proper phase of
imaging. There is medial splenic vein thrombosis seen today, in a portion the
was patent on MRI ___. There is expansion of both SMV and splenic
vein, suggesting acute thrombosis. There are multiple mesenteric collaterals.
There is persistent enlargement of the IVC .
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion. There is tiny pulmonary artery to pulmonary
vein fistula in the right lower lobe medially series 3, image 24.
ABDOMEN:
HEPATOBILIARY: The right lobe is small in size with enlargement of the left
lobe with macrolobular contour. Constellation of findings are consistent with
hepatic cirrhosis. No focal enhancing liver lesion is identified. There is
mild intrahepatic bile duct dilatation, similar to prior. There is no
extrahepatic bile duct 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 again seen mild
stranding around the pancreatic head and extending along the course of the
SMV.
SPLEEN: The spleen is surgically absent. Splenosis in the left upper quadrant
is unchanged.
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 wall thickness and
enhancement throughout. There is single loop wall of mildly dilated small
bowel loop in the right abdomen, this should be followed with serial x-rays
given ___ thrombosis to monitor for progressive dilatation. There are areas
of mild colonic wall thickening involving ascending, transverse and proximal
descending ___ be reactive, consider infectious or inflammatory
colitis, changes related to venous congestion. There is no pneumatosis
intestinalis, bowel wall thickening, or intraperitoneal free air suggest
mesenteric ischemia. Appendix contains air, has normal caliber without
evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy. There is moderate mesenteric stranding is small volume fluid
centrally. Trace perihepatic fluid.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. SMV and medial splenic vein thrombosis, both vessels are expanded with
central filling defect, suggesting acute to subacute to thrombus. There is
mild mesenteric stranding and small volume fluid. Single small bowel loop is
mildly dilated, has normal wall enhancement, consider follow-up serial
radiographs to exclude progressive dilatation. Mild wall thickening of the
ascending, transverse, descending ___ be reactive, infectious,
inflammatory or ischemic colitis should be considered.
3. Findings of hepatic cirrhosis. No focal enhancing liver lesion is
identified.
4. Chronic thrombosis of the portal vein with cavernous transformation of
multiple collaterals at the hepatic hilum.
NOTIFICATION: The findings and recommendations were communicated to the
referring physician via telephone to Dr. ___ at 9:23 ___ on ___
by Dr. ___.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Abnormal labs, Transfer
Diagnosed with Unspecified abdominal pain, Anemia, unspecified
temperature: 100.1
heartrate: 114.0
resprate: 18.0
o2sat: 98.0
sbp: 117.0
dbp: 72.0
level of pain: 9
level of acuity: 2.0 | HOSPITAL COURSE
===============
___ female with history of cirrhosis ___ schistosomiasis
s/p splenectomy c/b portal vein thrombosis, portal hypertension,
gastroesophageal varices who presents with three days of
abdominal pain and fever, found to have SMV thrombus and
symptomatic anemia with Hgb 6.5 likely multifactorial given hx
GIB, heavy menses, and consumptive in setting of acute thrombus,
for which she was started on a heparin drip. EGD significant for
one small esophageal varix and potential gastric varices,
without stigmata of recent bleed. ___ was consulted for possible
thrombectomy and TIPS. Given her surgical history of splenectomy
and cavernous transformation of her portal vein, the procedure
was felt to be technically difficult, and was deferred for a
trial of anticoagulation. The patient's pain resolved and the
patient was discharged on a Lovenox bridge to ___ with
close outpatient follow-up.
ACTIVE ISSUES
=============
# Abdominal pain
# Acute SMV Thrombus
# Anemia: She has history of gastric variceal hemorrhage, as
well as esophageal varices. Her anemia is notably microcytic
which would be consistent with bleed vs ___. Presented with
three days of abdominal pain and fever, found to have SMV
thrombus and symptomatic anemia with Hgb 6.5 likely
multifactorial given hx GIB, heavy menses, and consumptive in
setting of acute thrombus, for which she was started on a
heparin drip. EGD significant for one small esophageal varix and
potential gastric varices, without stigmata of recent bleed. ___
was consulted for possible thrombectomy and TIPS. Given her
surgical history of splenectomy and cavernous transformation of
her portal vein, the procedure was felt to be technically
difficult, and was deferred for a trial of anticoagulation. The
patient's pain resolved and the patient was discharged on a
Lovenox bridge to ___ with close outpatient follow-up.
# SIRS: fever + tachycardia, though no localizing infectious
source. Presumed due to infection or from ___ thrombosis itself.
Initially receive ceftriaxone but was subsequently discontinued
on ___ as no localizing signs of infection, low fevers
presumed due to clot as above.
# Cirrhosis
# Trasaminitis
Cirrhosis ___ schistosomiasis with history of PV thrombosis and
variceal bleeding. MELD 8 (11 on admission). ___ Class A.
AST/ALT mildly elevated, ratio approx 2. AP mildly elevated. T
___ normal at 0.6 on admission. LDH elevated at 900. LFTs
downtrended during admission but began to trend up at time of
discharge, to be followed up with outpatient labs.
# H/o schistosomiasis: Chronic, no treatment. S/p splenectomy.
TRANSITIONAL ISSUES
===================
[] Medications
- Enoxaparin Sodium 80 mg SC Q12H
- Warfarin 3mg daily
- Pantoprazole 40 mg PO Q24H
[] Of note, patient is eligible for a fourteen day supply of
medications from ___ free pharmacy, after which time, she will
need additional assistance in obtaining her medications
[] Patient with slight elevation in LFTs (ALT 91 AST 121) on
discharge; has standing labs ordered at ___ (LFTS, CBC, BMP)
to be checked on ___ and followed up by Dr. ___ Dr.
___
[] Check INR at ___ on ___ and follow up by Dr. ___
[] Protein C,S, and antithrombin III pending at the time of
discharge
[] Will attempt to coordinate an earlier appointment with Dr.
___ at the beginning of ___
# Code: Full
# Communication: ___ (boyfriend) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Haldol / Seroquel
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old woman with a history of narcolepsy
with cataplexy and NPH s/p VPS in ___ who presented s/p fall.
The patient fell in her bathroom on ___. She hit her head
on the toilet, but did not lose consciousness. She crawled to
the living room, where a nurse found her. She was originally
admitted to ___, where a CT scan showed a
1cm right frontal subdural bleed. She was transferred from ___
to ___. On arrival to the ED, she had vitals T97.4 BP 120/74
HR 74 R 16 O2 98% RA. Exam was deferred because the patient was
"uncooperative." A repeat head CT showed that the SDH had not
increased in size, there was no new hemorrhage and the VPS shunt
was in place.
Past Medical History:
1. Narcolepsy w/cataplexy, as above
2. NPH s/p VP shunt in ___ (@OSH) -- last shunt series was in
___, unremarkable, and NCHCT at that time showed decompressed
ventricular system (albeit with no prior images for comparison)
3. s/p lumbar spine fusion complicated by MRSA bacteremia,
requiring R-knee hardware removal and replacement; chronic
Bactrim Tx since that time.
4. s/p bilateral knee replacements and repeat of R-knee after
MRSA-bacteremia in ___
5. Frequent, recurrent UTIs
6. h/o chest pain with + cardiac stress in ___ (details unknown
to me at this time -- no echo or vessel/stress data in OMR...
ECGs appear benign here and patient has been asx and HDS here)
7. s/p Thyroid ablation, Thyroid nodules, being monitored
8. s/p cholecystectomy
9. Osteoarthritis
10. chronic spastic bladder (Vesicare recently d/c'd)
11. chronic mild dysphagia (cause = ?) on mech soft diet and
thin
liquids. also, pt has only upper dentures
Social History:
___
Family History:
Daughter - mitral valve disease. Maternal GM with
ateriosclerosis. Breast Ca in Sister. ___ in siblings.
Physical Exam:
ADMISSION EXAM
98.0 114/71 59 18 96%RA.
MS: ___. She is fluent with normal prosody. She did not
participate in memory recall or attention questions.
Cranial Nerves:
CNI: Not tested.
CNII: L pupil 3mm-->2mm. R pupil 3mm-->2mm. Visual fields full
to
confrontation.
CNIII, IV, VI: Extraocular movements intact. No nystagmus.
V: Sensitive to light touch in V1,2 and 3 distributions. Able to
clench jaw.
VII: No facial droop. Able to smile without asymmetry. Unable to
overcome eye closure bilaterally.
VIII: Able to hear finger-rub bilaterally.
IX, X: Able to elevate palate. Gag reflex not tested.
XI: SCM and shoulder shrug are full strength bilaterally.
XII: Tongue protrudes midline.
Motor: Normal bulk, tone throughout. No adventitious movements
noted. No pronator drift.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Sensitive to light touch and pinprick sensation in
bilateral upper and lower extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 1 1
R 3 3 3 1 1
Plantar response was flexor on L and R.
Coordination: Able to perform finger-to-nose bilaterally. Slowed
cadence on L rapid finger movements; right rapid finger
movements
were normal.
DISCHARGE EXAM:
97.9 97.0 131/57 61 18
MS: ___ month/date, but not to place, hospital. Can attend to
the examiner. Perserverates on "thank you" but can answer some
questions appropriately. Follows most commands.
Motor: Normal bulk, tone throughout. No adventitious movements
noted. No pronator drift.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Sensitive to light touch in bilateral upper and lower
extremities.
- Coordination: Able to perform finger-to-nose bilaterally.
Pertinent Results:
Cardiovascular Report ECG Study Date of ___ 2:09:40 ___
Sinus rhythm. Diffuse modest ST-T wave changes which are
non-specific.
Compared to the previous tracing of ___ there are modest
inferior
ST-T wave changes which are more pronounced.
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 192 84 384/434 55 44 24
_____________________________
Radiology Report CT C-SPINE W/O CONTRAST Study Date of ___
2:06 ___
IMPRESSION:
1. Moderate degenerative changes.
2. No evidence for fracture.
3. Findings at the lung apices suggesting pulmonary vascular
congestion.
4. Heterogeneous thyroid probably reflecting nodules which could
be examined in more detail by ultrasound if clinically
indicated.
_______________________________
Radiology Report HIP 1 VIEW Study Date of ___ 10:36 ___
CONCLUSION:
No good evidence of acute fracture.
_______________________________
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
6:56 AM IMPRESSION:
1. No gross change in the size of the right frontal subdural
hematoma or its mild mass effect.
2. No new focus of hemorrhage.
3. Stable prominence of the ventricles with a ventriculostomy
catheter in
unchanged position.
___ 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:40PM ___ PTT-32.1 ___
___ 02:40PM PLT COUNT-232
___ 02:40PM NEUTS-80.1* LYMPHS-16.1* MONOS-3.2 EOS-0.6
BASOS-0.1
___ 02:40PM WBC-6.8 RBC-3.61* HGB-10.8* HCT-32.4* MCV-90#
MCH-30.0 MCHC-33.4 RDW-12.6
___ 02:40PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-2.0
___ 02:40PM CK-MB-2
___ 02:40PM cTropnT-<0.01
___ 02:40PM CK(CPK)-30
___ 02:40PM estGFR-Using this
___ 02:40PM GLUCOSE-96 UREA N-28* CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-11
___ 04:02PM PLT COUNT-230
TSH 3.8, FT4 0.99, CRP 31.8, ESR 58
___ Urine Cx negative
___ Urine Cx
___ 2:07 pm URINE Site: NOT SPECIFIED
GRAY TOP HOLD # ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Medications on Admission:
1. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or ___.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days: Course to finish on ___.
13. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Zyprexa 2.5 mg Tablet Sig: 0.5 Tablet PO twice a day as
needed for agitation.
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): for MRSA prophylaxis.
Disp:*30 Capsule(s)* Refills:*2*
5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain or fever > 101.5.
9. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. venlafaxine 150 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: in the morning.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
11. sertraline 50 mg Tablet Sig: Three (3) Tablet PO at bedtime.
12. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take only if systolic blood pressure >160.
Disp:*30 Tablet(s)* Refills:*2*
13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days: for treatment of E.coli UTI.
Disp:*24 Tablet(s)* Refills:*0*
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Xyrem 500 mg/mL Solution Sig: 3.75 mg PO twice nightly:
administer 3.75 mg by mouth at bedtime and 3.75 mg by mouth ___
hours later.
Disp:*2 weeks* Refills:*0*
17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Right Frontal Subdural Hemorrhage, Urinary
Tract Infection
Secondary Diagnosis: Cataplexy, Narcolepsy, Normal Pressure
Hydrocephalus, Dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Awake, alert, oriented to place, hospital, time.
Speech fluent and answers most questions appropriately.
Otherwise nonfocal.
Followup Instructions:
___
Radiology Report
CT OF THE CERVICAL SPINE
HISTORY: Combative dementia and unwitnessed fall, with presentation to
outside hospital with subdural hematoma, hip pain and tenderness overlying T3
and T4
COMPARISONS: An outside head CT is available from ___.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDINGS:
There is no evidence for fracture, dislocation or bone destruction. Moderate
degenerative changes involve the cervical spine. The upper thoracic spine
including T3 and T4 are not fully imaged.
Degenerative changes are moderate at the anterior C1-C2 articulation including
fragmented osteophytes and periarticular calcification. The C3-C4 interspace
is largely calcified, with a posterior disc bulge and mild neural foraminal
narrowing on the right by uncovertebral joint osteophytes. There is also mild
right-sided neural foraminal narrowing at C4-C5 and bilaterally at C5-C6
association with facet and uncovertebral joint osteophytes. Facet joint
degenerative changes are most striking on the left at C3-C4 and C4-C5 and on
the right at C5-C6. Mild facet joint degenerative changes are present at
C6-C7 bilaterally. Facet joint changes are moderate at C7-T1 level on the
right. Minimal spondylolisthesis of C7 on T1 is probably due to facet joint
degenerative changes, which are so again moderately prominent on the right
side.
The lung apices show thickened interlobular septa and patchy ground glass
opacification suggesting pulmonary congestion. The thyroid is heterogeneous,
probably reflecting multiple nodules. The right lobe is attenuated with
patchy calcification. Patchy vascular calcifications are also noted along
each carotid bulb. Vascular calcifications are widespread and striking along
the course of the left vertebral artery.
IMPRESSION:
1. Moderate degenerative changes.
2. No evidence for fracture.
3. Findings at the lung apices suggesting pulmonary vascular congestion.
4. Heterogeneous thyroid probably reflecting nodules which could be examined
in more detail by ultrasound if clinically indicated.
Radiology Report
STUDY: AP pelvis and mages of left hip.
INDICATION: Patient with cognitive dementia, transferred in with history of
subdural hematoma and left hip pain.
TECHNIQUE: AP pelvis, single view left hip was obtained.
COMPARISON: None.
REPORT:
The examination is markedly limited, but within this limitation, a single AP
view of the pelvis does not definitively reveal a fracture. Degenerative
changes are noted in the symphysis pubis. Degenerative change also noted in
both hips.
CONCLUSION:
No good evidence of acute fracture.
Radiology Report
INDICATION: Evaluate for interval change of subdural hematoma.
COMPARISONS: CT head ___. CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: A left frontal approach ventriculostomy catheter is in an unchanged
position near the septum pellucidum. The ventricles are mildly prominent
which is unchanged from prior exams. A right frontal hyperdense extra-axial
collection appears grossly unchanged in size. The apparent difference in size
is likely due to a substantial difference in the plane of scanning. There is
mild mass effect with some effacement of the adjacent sulci, but no shift of
the normal midline structures or effacement of the cisterns. The basal
cisterns appear patent. There are no new foci of hemorrhage. There is no
evidence of infarction.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are unremarkable.
IMPRESSION:
1. No gross change in the size of the right frontal subdural hematoma or its
mild mass effect.
2. No new focus of hemorrhage.
3. Stable prominence of the ventricles with a ventriculostomy catheter in
unchanged position.
Radiology Report
INDICATION: ___ female, status post fall with right elbow pain, point
tenderness, worse with movement.
COMPARISONS: None available.
TECHNIQUE: Right elbow, three views.
FINDINGS: Assessment of the right elbow is limited as the lateral view was
taken with the elbow in extension. Allowing for these limitations, an
equivocal positive posterior fat pad sign is present, which is concerning for
a periarticular fracture. There are no focal osseous lesions or radiopaque
foreign objects.
IMPRESSION: Probable periarticular fracture. Further assessment is needed
with a proper lateral view with a flexed elbow.
These concerns were communicated by Dr. ___ to ___
___ via telephone on ___ at 4:45 p.m.
Radiology Report
STUDY: Single lateral view of the right elbow ___.
COMPARISON: Radiographs earlier the same day.
INDICATION: Multiple falls and right elbow pain.
FINDINGS: Unremarkable soft tissues. Anterior fat pad sign and small
posterior fat pad, consistent with a small joint effusion. However, on the
single view no definite fracture identified.
IMPRESSION: Small elbow joint effusion. If there is concern for an occult
fracture, recommend further evaluation with CT.
Radiology Report
CHEST
HISTORY: Cough and chest pain, question infiltrate.
REFERENCE EXAM: ___.
FINDINGS: Shunt tubing is coursing over the right lateral chest. The heart
is upper limits normal in size. There are some patchy areas of alveolar
opacity. It could represent areas of volume loss or early infiltrate. These
are more conspicuous than on the prior exam from ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL SDH
Diagnosed with TRAUMATIC BRAIN HEM NEC, OPEN WOUND OF SCALP, UNSPECIFIED FALL, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE, ALZHEIMER'S DISEASE
temperature: 97.4
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 120.0
dbp: 74.0
level of pain: 13
level of acuity: 2.0 | ___ with a history of narcolepsy with cataplexy and NPH s/p
VPS in ___ who presented s/p fall with ___ diagnosed on head CT
___.
[] Subdural Hemorrhage. On ___, patient was admitted to the
SICU and monitored overnight. A repeat Head CT was done on the
morning of ___ which showed that the SDH had not increased in
size, there was no new hemorrhage and the VPS shunt was in
place. No focal deficits were identified on serial neuro exams.
She was started on Dilantin 100 mg TID. On ___, the patient was
transferred to the step-down unit. She remained neurologically
intact. Physical therapy consult was initiated and patient was
able to be OOB with assistance. On ___, the Dilantin level was
1.8 and the patient was transitioned to Keppra 500mg po BID. On
___, the patient was transferred to inpatient neurology for
further management. She has no further seizures. Levetiracetam,
despite its possible behavioral effects, was thought to be the
best choice (other than phenytoin) for prevention of seizures
from intracranial hemorrhage.
[] Narcolepsy. Per daughter, the patient's narcolepsy appears to
be worse in the hospital. She was having more episodes of
cataplexy and falling asleep more frequently. On ___, the
patient's neurologist Dr. ___ was contacted, and he asked
that her Venlafaxine be changed from BID dosing to once daily
(in the morning) as previously prescribed. After much
discussion, her prior medication of Xyrem will likely be
restarted as an outpatient (3.75 at bedtime and 3.75 grams ___
hours later). If that is the case, her Olanzapine will need to
be stopped, and her Venlafaxine and Sertraline will need to be
readdressed as to their utility. She will follow-up with Dr.
___ discharge.
***Once XYREM is restarted, please contact Dr. ___ at
___ to determine what other medications should be
discontinued. DO NOT ADMINISTER OLANZAPINE (ZYPREXA) IF XYREM IS
RESTARTED.***
[] Combativeness/Aggression. On ___ and ___, the patient was
agitated and combative, requiring restraints on both nights. She
had not been written for olanzapine as she previously was
prescribed. She was found to have received twice her normal dose
of Zyprexa in the previous day. The patient was returned to her
home (___) dose of the medication on ___. Her mental status
improved. She has been alert and oriented x3 and intermittently
x2 since then. She has been off restraints for more than 24
hours and has been much calmer after treatment of her UTI and
correction of her medications.
[] Chest pain. On ___, the patient reported brief chest pain
and several gagging episodes associated with coughing but no
frank vomiting. EKG was normal. Cardiac enzymes x2 were normal.
CXR showed atelectasis. The transient chest pain associated with
gagging episode was attributed to GERD, and famotidine was
started empirically. Due to potential anticholinergic effects,
Geriatrics recommeded changing to an alternate medication.
Calcium carbonate was used instead.
twice daily
[] Right arm pain. On ___ the patient complained of right
elbow pain which was diffuse and more painful with movement. A
right elbow xray was ordered and appeared grossly normal.
[] UTI. The patient has a history of recurrent UTIs. She had a
normal UA and UCx on admission but was subsequently
catheterized. The second urinary culture grew E.coli resistant
to TMP-SMX and Ciprofloxacin but sensitive to Ceftriaxone. She
has been afebrile and denies any symptoms. She was treated with
Cefpodoxime 200 mg BID x 7 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
shellfish derived / lisinopril
Attending: ___.
Chief Complaint:
double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ M with extensive PMHx including
ESRD on peritoneal dialysis, prior history of non-arteritic
anterior ischemic
optic neuropathy of the right eye, HTN who presents with double
vision upon waking this morning. Over the past week or so the
patient has been
feeling increasingly tired and fatigued. He has not been eating
well and has been nauseous. He was seen in urgent care two day
prior to presentation and was diagnosed with a probable UTI and
started on ciprofloxacin. This morning he awoke and noticed that
he was having trouble reading due to blurry vision. He looked up
and at a distance he noticed double vision which he states is
worse when looking farther away and when looking to the left.
The
double vision goes away when he closes one eye. He states that
he
has had increasing difficulty walking with his walker over
recent
days but has not noticed any focal weakness. He has not had any
numbness. He denies room spinning dizziness.
The patient tells me that he has only been taking his 81mg
aspirin 3 times per week, when he remembers due to concerns
about
anemia and easy bruising. He also tells me that he has had
difficulty moving his right foot and toes over the past months.
He has had an MRI of his back and his doctors have told ___ that
this is due to a pinched nerve in the back.
On neuro ROS, the pt denies headache, loss of vision,
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.
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:
1. Colon Cancer s/p resection in ___
2. BPH s/p TURP
3. Chronic Renal failure, on Peritoneal dialysis since ___
4. Hypertension
5. Hypothyroidism
6. Aortic Insufficiency
7. First degree AV block
8. Macrocytic Anemia/Myelodysplastic syndrome
9. Shrapnel in leg from WWII
10. Anterior ischemic optic neuropathy (non-arteritic) of the
right eye
PSH:
1. Laproscopic anterior ___
2. Right Inguinal hernia ___
3. Transrectal prostatic biopsy, ___
4. Laparoscopic Tenckhoff Catheter, ___, ___
5. Lap Tenckhoff Catheter repositioning ___, ___
6. Removal and replacment of PD catheter (___)
7. Left inguinal hernia repair (___)
Social History:
___
Family History:
Father - deceased at ___, CVA, angina in ___. Mother - deceased
at ___, "leaky valve." 1 brother - deceased at ___, MI, CVA. 3
children, 4 grandchildren.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals:
97.6 67 116/24 20 100%
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple.
RESP: non-labored
CV: RRR
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Alert, oriented x 3.
Able to relate history without difficulty.
Mildly inattentive
Language is fluent with intact comprehension.
Normal prosody.
There were no paraphasic errors.
Speech was not dysarthric.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 2 to 1mm and brisk.
RUQ anopsia bilaterally. Difficulty counting fingers in all
peripheral fields on right, able to identify moving fingers.
III, IV, VI: EOMI on rightward, upward and downward gaze. On
left
gaze the right eye does not fully adduct and there is nystagmus
of the left eye. Concergence of the right eye also appears to be
impaired.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
No pronator drift bilaterally.
No adventitious movements. Asterixis noted.
Delt Bic Tri WrE FE IO IP Quad Ham TA ___
L ___ ___ 4+ 5 ___ 4-
R ___ ___ 5 5 ___ 0
Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 0* 0
R ___ 0* 0
Right toe down, left toe up
*s/p ___ TKA
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF or foot to hand bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
language fluent and appropriate, can give accurate hx. Conjugate
gaze, EOMI but unsustained lateral gaze. Impaired visual field
on L; vision is ___ -2 b/l. No facial asymmetry, facial
sensation intact. No pronator drift. Muscle wasting at thenar
eminence and first dorsal interosseous. Asymmetric decreased
stregth in R>L TA. No fatiguability in deltoids. No clonus,
semi-increased tone in LEs, normal tone in UEs. Patchy
distribution of impaired pinprick L>R. LT and temp intact, poor
proprioception b/l.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:25PM BLOOD WBC-6.6 RBC-3.18* Hgb-10.5* Hct-33.3*
MCV-105* MCH-33.0* MCHC-31.6 RDW-16.4* Plt ___
___ 02:25PM BLOOD Neuts-75.4* Lymphs-12.1* Monos-7.0
Eos-4.9* Baso-0.6
___ 02:42PM BLOOD ___ PTT-33.7 ___
___ 02:25PM BLOOD Glucose-110* UreaN-91* Creat-8.6* Na-132*
K-3.5 Cl-89* HCO3-23 AnGap-24*
___ 02:25PM BLOOD ALT-24 AST-28 AlkPhos-61 TotBili-0.1
___ 02:25PM BLOOD Albumin-3.2* Calcium-8.5 Phos-6.8*
Mg-2.8*
___ 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-20
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT LABS:
===============
___ 02:25PM BLOOD cTropnT-0.32*
___ 04:59AM BLOOD CK-MB-13* MB Indx-6.0 cTropnT-0.33*
___ 04:59AM BLOOD %HbA1c-5.5 eAG-111
___ 04:59AM BLOOD Triglyc-122 HDL-44 CHOL/HD-3.2 LDLcalc-72
___ 02:25PM BLOOD TSH-13*
___ 02:25PM BLOOD CRP-16.1*
DISCHARGE LABS:
===============
___ 04:59AM BLOOD WBC-5.1 RBC-2.79* Hgb-9.3* Hct-29.4*
MCV-105* MCH-33.2* MCHC-31.6 RDW-16.5* Plt ___
___ 04:59AM BLOOD Glucose-72 UreaN-99* Creat-9.4* Na-133
K-3.9 Cl-90* HCO3-22 AnGap-25*
___ 04:59AM BLOOD ALT-22 AST-24 CK(CPK)-216 AlkPhos-52
TotBili-0.1
___ 04:59AM BLOOD Albumin-2.7* Calcium-8.7 Phos-7.6*
Mg-2.9* Cholest-140
RELEVANT STUDIES:
=================
- EKG (___): Sinus bradycardia. Right bundle-branch block.
Leftward axis. ST-T wave flattening in the inferior leads,
similar to that recorded on ___. Baseline artifact persists
without diagnostic interim change.
- CT HEAD W/O CONTRAST (___): No evidence of acute
intracranial abnormality.
- MRA HEAD AND NECK (___):
1. Essentially unremarkable noncontrast enhanced MRI of the
brain.
2. Unremarkable MRA of the head and neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 20 mg PO DAILY
2. Lactulose 15 mL PO DAILY:PRN constipation
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic prn
5. Omeprazole 40 mg PO BID
6. Pravastatin 20 mg PO DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Tamsulosin 0.4 mg PO DAILY
9. TraZODone 100 mg PO HS:PRN insomnia
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Acetaminophen 1000 mg PO Q8H:PRN pain
12. Aspirin 81 mg PO DAILY
13. Cetirizine 10 mg PO DAILY
14. Docusate Sodium 240 mg PO AFTER EACH MEAL
15. Vitamin D ___ UNIT PO DAILY
16. Polyethylene Glycol ___ g PO DAILY
17. Simethicone 180 mg PO BID:PRN gas pain
18. Nephrocaps 1 CAP PO DAILY
19. Calcitriol 0.25 mcg PO DAILY
20. Calcium Acetate 667 mg PO DAILY
21. Epoetin Alfa 30,000 units SC Q2WEEKS
22. Finasteride 5 mg PO DAILY
23. Ciprofloxacin HCl 500 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Docusate Sodium 240 mg PO AFTER EACH MEAL
6. Finasteride 5 mg PO DAILY
7. Fluoxetine 20 mg PO DAILY
8. Lactulose 15 mL PO DAILY:PRN constipation
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 40 mg PO BID
12. Polyethylene Glycol ___ g PO DAILY
13. Pravastatin 20 mg PO DAILY
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Simethicone 180 mg PO BID:PRN gas pain
16. Senna 8.6 mg PO BID:PRN constipation
17. Cetirizine 10 mg PO DAILY
18. Epoetin Alfa 30,000 units SC Q2WEEKS
19. Lotemax (loteprednol etabonate) 0.5 % ophthalmic prn
20. Tamsulosin 0.4 mg PO DAILY
21. TraZODone 100 mg PO HS:PRN insomnia
22. Vitamin D ___ UNIT PO DAILY
23. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
24. Ciprofloxacin HCl 500 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
transient diplopia and right medial rectus palsy
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: History: ___ with visual field cut // ? stroke
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 891 mGy-cm
CTDI: 54 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
large territorial infarction. The ventricles and sulci are prominent
compatible with age related atrophy. The basal cisterns are patent. Gray-white
matter differentiation is preserved. There is no fracture. The included
paranasal sinuses, mastoid air cells and middle ear cavities are clear except
for minimal mucosal thickening in the ethmoidal air cells. There is no
fracture.
IMPRESSION:
No evidence of acute intracranial abnormality.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old man with R INO, left sided weakness // stroke?
TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR,
susceptibility and diffusion weighted images were obtained through the head.
Three dimensional time of flight MR arteriography of the head, and two
dimensional time of flight MR arteriography of the neck were performed with
rotational reconstructions.
COMPARISON: CT head without contrast of ___ for, MR pituitary
with and without contrast of ___.
FINDINGS:
MRI HEAD: There is no intra or extra-axial mass effect, acute hemorrhage or
infarct. Sulci, ventricles and cisterns are within expected limits for the
degree of age appropriate volume loss. There are minimal subcortical and
periventricular nonspecific FLAIR/ T2 white matter hyperintensities, which is
commonly seen in setting of small vessel ischemic disease in a patient of this
age. The major intracranial flow voids are preserved. Mild mucosal thickening
of ethmoid air cells is noted otherwise the paranasal sinuses are essentially
clear. The patient is status post bilateral lens replacements otherwise
orbits are unremarkable. The mastoid air cells are clear.
HEAD MRA: Normal flow related signal is seen in the intracranial internal
carotid, middle cerebral and anterior cerebral arteries without significant
mural irregularity or stenosis. There is normal symmetric arborization of the
MCA branches. There is no aneurysm greater than 3 mm. Normal flow related
signal is seen in the right dominant intracranial vertebral arteries, the
basilar artery, and the bilateral superior cerebellar and posterior cerebral
arteries.
NECK MRA: The cervical common carotid, internal carotid and external carotid
arteries are normal in course, caliber and contour. They demonstrate normal
flow related signal without mural irregularity, stenosis or evidence of
dissection. The right dominant vertebral arteries are normal in course,
caliber and contour. They demonstrate normal flow related signal without mural
irregularity, stenosis or evidence of dissection.
IMPRESSION:
1. Essentially unremarkable noncontrast enhanced MRI of the brain.
2. Unremarkable MRA of the head and neck.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, Vision changes
Diagnosed with DIPLOPIA
temperature: 97.6
heartrate: 67.0
resprate: 20.0
o2sat: 100.0
sbp: 116.0
dbp: 24.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ year old man with an extensive past
medical history, including end-stage renal disease on peritoneal
dialysis, prior history of possible anterior ischemic optic
neuropathy, hypertension, atrial fibrillation, and spinal
stenosis, who presents with double vision upon waking the
morning before admission. He was admitted overnight, after which
his diploplia resolved spontaneously. However, he then noted
decreased vision in his left eye. He had impaired left visual
field on his right eye on exam (most likely chronic). However,
visual acuity appeared to be equal in both eyes and mostly
intact. Otherwise, his exam was only notable for findings
consistent with cervical spinal stenosis. A non-contrast head CT
and an MRI of his head and MRA brain/neck were performed, and
all imaging was negative for any signs of acute stroke. Pt was
most likely experiencing a microischemic cranial neuropathy,
causing transient medial rectus palsy. Myasthenia ___ was
also considered, but is a less likely diagnosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
sodium pentathol / dust / pollen / ragweed pollen
Attending: ___.
Chief Complaint:
Confusion and falls
Major Surgical or Invasive Procedure:
- ___: LP attempted and aborted due to small hematoma
formation
History of Present Illness:
___ with hx metastatic breast cancer (known metastases to bone
and liver), blindness ___ congenital glaucoma, depression, and
asthma who was referred from ___'s office for subacute mental
status decline and increasing falls at home.
Patient increased falls over the last several months, she thinks
5 since ___. Her husband notes she has had several in the last
few weeks, and she is now entirely dependent on him to help her
move around without falling. She reports significant 'shakiness'
and weakness when standing, more pronounced in the right leg.
She denies vertigo or presycnopal symptoms. Her last fall was
1.5 weeks ago with no head strike or LOC. Her husband also has
noted some dysarthria and possible confusion. For these
symptoms, she was referred to the ED.
In the ED, initial VS were 98.2 83 119/64 14 100% RA. Labs were
notable for Chem-7 wnl with Cr 0.8 (baseline Cr 0.8-1.0), LFTs
wnl, CBC at baseline with H/H 8.3/25.9 (baseline Hct ___, INR
1.2. CT Head prelim read without acute process. CXR with no
acute process but noted widespread osseous metastases. The
patient is now admitted to ___ for further treatment and
management. VS prior to transfer T 98.1, HR 84, BP 113/62, RR
18, O2 97%RA.
On arrival to the floor, patient has no acute complaint. Denies
recent fevers or chills. She has occaisional sinus headaches,
but non currently. She has some residual vision at baseline
which has not changed. No SOB, mild chronic cough, no chest
pain. No N/V/D. No abdominal pain. She has increased urinary
frequency but no dysuria. No edema. She has had a small skin
lesion on her right foot, for which she is currently holding her
xeloda. Of note, she recently stopped her diabetes meds several
months ago, which seems to correspond with the worsening of her
weakness/balance. ROS is otherwise unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY: For full Onco history, please see
Atrius records. Briefly: Breast cancer, initially on the right
side in ___ with DCIS on the left with microinvasion. First
metastasis was in ___ to bone and liver. She has had stable
disease now ___ years. She taking the Xeloda and Zometa every
three months.
PAST MEDICAL HISTORY:
Congenital glaucoma and related blindness
HTN
Asthma
GERD
CKD, baseline Cr
Allergic rhinitis
IBS
Depression
Uterine fibroids
+PPD
Social History:
___
Family History:
Father ___ - Type II; Psych - Depression; Stroke
Mother Cancer - ___
Paternal Aunt Cancer
Son ___ - Type I
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VS: BP 108/64 HR 88 RR 20 T 98.5
GENERAL: Pleasant, frail woman. NAD.
HEENT: NC/AT, legally blind with marked saccades at rest. PERLL.
Anicteric. Dry MM.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema. Right foot with 1cm
fissure without surrounding erythema or drainage
NEURO: Oriented to person and place. Answers ___ for month.
Fair attention. Blind. PERLL. Marked saccades at rest. Moves
eyes on command to all four quadrants. Attends to examiner.
Slight right facial droop. Tongue and Pharanyx is midline. 3+/5
strength right shoulder. ___ throughout rest of upper
extremities, although exam limited by patient. Marked intention
tremor bilaterally during FTN and noticeable DDK. Poor HTS,
worse on right. Good antigravity strength throughout both lower
extremities.
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.7 ___ 70 16 97-99RA
GENERAL: Pleasant, frail woman. NAD.
HEENT: NC/AT. Blind with saccades at rest. Anicteric sclera. Dry
MM.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4.
LUNG: Clear to auscultation, no wheezes or rhonchi.
ABD: +BS, soft, NT/ND, no rebound or guarding.
BACK: Small soft hematoma at L3, with dressing coming off but no
bleeding or erythema. Nontender.
EXT: No lower extremity pitting edema. Right foot with 1-cm
fissure without surrounding erythema or drainage.
NEURO: A&Ox3. Blind with marked saccades at rest. Otherwise CN
II-XII intact. 4+/5 strength, overall ___ throughout. Marked
tremor and ataxia, worse on right. Normal finger to nose.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 01:35PM BLOOD WBC-6.4 RBC-2.61* Hgb-8.3* Hct-25.9*
MCV-99* MCH-31.8 MCHC-32.0 RDW-14.2 RDWSD-51.2* Plt ___
___ 01:35PM BLOOD Neuts-82.6* Lymphs-9.4* Monos-6.6
Eos-0.8* Baso-0.3 Im ___ AbsNeut-5.26 AbsLymp-0.60*
AbsMono-0.42 AbsEos-0.05 AbsBaso-0.02
___:35PM BLOOD ___ PTT-29.3 ___
___ 01:35PM BLOOD Glucose-254* UreaN-18 Creat-0.8 Na-134
K-3.9 Cl-94* HCO3-29 AnGap-15
___ 01:35PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.7 Mg-2.2
___ 01:35PM BLOOD ALT-17 AST-34 AlkPhos-93 TotBili-0.5
=========
KEY LABS:
=========
___ 09:15AM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 01:35PM BLOOD VitB12-230* Folate-12.5
___ 07:00AM BLOOD Ferritn-713*
___ 09:02AM BLOOD %HbA1c-7.0* eAG-154*
___ 07:55AM BLOOD CEA-2.0 ___
=================
DISCHARGE LABS:
=================
___ 07:33AM BLOOD WBC-5.4 RBC-2.84* Hgb-9.1* Hct-28.0*
MCV-99* MCH-32.0 MCHC-32.5 RDW-14.3 RDWSD-51.9* Plt ___
___ 07:33AM BLOOD Glucose-176* UreaN-23* Creat-0.9 Na-137
K-4.3 Cl-97 HCO3-29 AnGap-15
___ 07:33AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0
========
IMAGING:
========
___ MRI HEAD: Several T1 hypo intense and enhancing
calvarial lesions worrisome for metastatic disease. No evidence
of intracranial disease involvement.
___ MRI C/T/L SPINE:
1. Diffusely abnormal bone marrow signal in the cervical,
thoracic, and lumbar
spine, as well as included upper sacrum and medial iliac bones,
indicating
diffuse metastatic disease.
2. Mild loss of height involving several cervical and thoracic
vertebral bodies is noted, unchanged in the thoracic spine
compared to the ___ torso CT. No prior cervical spine
imaging for comparison.
3. No evidence for epidural or leptomeningeal metastatic
disease.
4. Multilevel cervical degenerative disease with moderate spinal
canal stenosis and moderate to severe neural foraminal
narrowing.
5. Mild thoracic and lumbar degenerative disease without
evidence for neural impingement.
6. Stable 15 mm oval nodule in the right upper gluteal
subcutaneous soft tissues, of uncertain clinical significance
given partial fat density on the prior CT, but no evidence for
fat on the present MRI on which it is incompletely evaluated.
___ CT ABD PELVIS:
1. Of the 3 previously identified hypodense liver lesions, only
2 are seen, relatively similar in size. Interval stability is
reassuring however not diagnostic for a benign process.
2. Stable thickening of the left adrenal gland.
3. Stable soft tissue mass in the left adnexa, of unclear
etiology.
4. Diffuse osseous metastases. No compression deformities in
the lumbar
spine.
___ CT CHEST 1. No evidence of metastatic disease to the
pleura, mediastinum, or pulmonary parenchyma.
2. Numerous osseous metastases, not significantly changed from ___, and no pathologic compression deformity in the
thoracic spine or acute pathological rib fractures.
3. Previously identified areas of ground-glass in the upper
lobes bilaterally have resolved since the prior study.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 200 mg PO DAILY
2. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety
3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
4. Atenolol 25 mg PO DAILY
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Simvastatin 20 mg PO QPM
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Atenolol 25 mg PO DAILY
4. BuPROPion (Sustained Release) 300 mg PO QAM
5. Lorazepam 0.5 mg PO QHS:PRN insomnia/anxiety
6. Sertraline 200 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation DAILY
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Breast Cancer, metastatic to bone
- Right acetabular fracture
SECONDARY DIAGNOSIS:
- Blindness secondary to glaucoma
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: History: ___ with breast cancer, confusion
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: Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Mild
prominence of the ventricles and sulci are consistent with age-related
involutional changes. Periventricular and subcortical white matter
hypodensities are seen, likely sequelae of chronic small vessel ischemic
disease. Basal cisterns are patent and there is preservation of gray-white
matter differentiation.
No osseous abnormalities seen. The right mastoid air cells a right ethmoid
air cell are partially opacified. Otherwise, the remaining paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with altered mental status// Eval for infiltrate
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: CT chest ___
FINDINGS:
Heart size is normal. Mediastinal and hilar contours are unchanged with
enlargement of the pulmonary arteries again noted suggestive underlying
pulmonary arterial hypertension. Pulmonary vasculature is not engorged. No
focal consolidation, pleural effusion or pneumothorax is present. Multiple
right axillary clips are re- demonstrated. Diffuse sclerosis of the osseous
structures is compatible with widespread metastatic disease.
IMPRESSION:
No acute cardiopulmonary abnormality. Widespread osseous metastases.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old female with hx of metastatic breast cancer presenting
with increasing falls in dysarthria. Evaluate for intracranial metastatic
disease.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON None.
FINDINGS:
Limited and incomplete exam with no contrast administered due to significant
patient motion. However, given the limited sequences acquired, in no large
mass or midline shift is identified.
IMPRESSION:
1. Nondiagnostic and incomplete exam given significant patient motion. A
repeat MRI is recommended when the patient is able tolerate the study.
RECOMMENDATION(S): Repeat MRI recommended.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with metastatic breast cancer and new
tachycardia // Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the left posterior tibial and peroneal
veins. Normal color flow is demonstrated in the right posterior tibial and
peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No medial popliteal fossa (___) cyst. Small left knee joint effusion.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Small left knee joint effusion.
RECOMMENDATION(S): Updated impression was discussed with ___ by Dr. ___
___ telephone at 19:56 on ___, 5 min after discovery.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ with metastatic breast cancer presenting with subacute mental
status changes and ataxia //
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5 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 dated ___.
FINDINGS:
There is no evidence of hemorrhage, edema, or mass effect. Ventricles and
sulci are age appropriate in size and configuration. There is no shift of
normally midline structures. Basal cisterns are patent. There is no
extra-axial fluid collection. There is no enhancing lesion identified on the
postcontrast sequences. No evidence of slow diffusion to suggest acute
infarction.
Several enhancing T1 hypo intense lesions are identified within the calvarium
including the right frontal bone (1000 01:49), right parietal superiorly
(1001:135), right parietal bone inferiorly (1001:139) left frontal along the
midline (1000:85) worrisome for metastatic disease.
Intracranial flow voids are preserved. The orbits are unremarkable.
Visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
Several T1 hypo intense and enhancing calvarial lesions worrisome for
metastatic disease. No evidence of intracranial disease involvement.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 17:43 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Radiology Report
INDICATION: ___ old woman with metastatic breast cancer and weeks of
mental status decline, right-sided weakness, and ataxia. Please evaluated for
metastatic disease.
TECHNIQUE: Sagittal T1 weighted, T2 weighted, and fat-suppressed IDEAL images
of the cervical, thoracic, and lumbar spine with axial T2 weighted images.
Following intravenous gadolinium administration, sagittal and axial T1
weighted images of the cervical, thoracic, and lumbar spine were obtained.
COMPARISON: Torso CT from ___ is available for correlation. There is
no prior spine MRI available.
FINDINGS:
Correlation with the prior torso CT demonstrates that there are 7 cervical
vertebrae, 12 rib-bearing vertebrae, L1 with transitional anatomy involving a
short rudimentary ribs instead of transverse processes, and L2 through L4 with
conventional anatomy. The iliolumbar ligament is visualized at L5, as
expected. The numbering is documented on images 5:10 and 06:11.
CERVICAL SPINE MRI: Evaluation is mildly limited by motion artifact as well
as large field of view on the sagittal images.
Bone marrow signal is diffusely abnormal, low on precontrast T1 weighted
images with heterogeneous high signal on fat-suppressed IDEAL and postcontrast
T1 weighted images, consistent with diffuse metastatic infiltration. C5 and
C6 vertebral bodies demonstrated mild loss of height with inferior endplate
deformities, but due to the motion artifact it is not clear whether the
inferior endplate deformities are secondary to metastatic lesions or Schmorl's
nodes.
No epidural mass is identified. No pathologic leptomeningeal contrast
enhancement is seen.
Minimal retrolisthesis of C3 on C4 and of C6 on C7 is likely degenerative.
The cerebellar tonsils are normally positioned, and the craniocervical
junction appears unremarkable. The intracranial compartment is better
assessed on the brain MRI from ___.
At C2-C3, there is no spinal canal or neural foraminal narrowing.
At C3-C4, mild retrolisthesis with posterior endplate osteophytes moderately
narrow the spinal canal and indents the ventral spinal cord. Evaluation of
cord signal is limited by artifacts on sagittal images. No definite cord
signal abnormality seen on axial images. Moderate to severe right and
moderate left neural foraminal narrowing by uncovertebral and facet
osteophytes is present.
At C4-C5, posterior endplate osteophytes moderately narrow the spinal canal
and flatten the ventral spinal cord. Evaluation of cord signal on sagittal
images is limited by artifacts. No definite cord signal abnormality is seen
on axial images. Mild to moderate right and moderate to severe left neural
foraminal narrowing by uncovertebral and facet osteophytes is present.
At C5-C6, posterior endplate osteophytes and thickening of the ligamentum
flavum result in moderate to severe narrowing of the spinal canal with
flattening of the ventral spinal cord. Evaluation of cord signal on sagittal
images is limited by artifacts. No definite cord signal abnormality seen on
axial images. There is moderate right and severe left neural foraminal
narrowing by uncovertebral and facet osteophytes.
At C6-C7, posterior endplate osteophytes indent the ventral thecal sac but do
not contact the spinal cord. There is moderate right and mild left neural
foraminal narrowing by uncovertebral and facet osteophytes.
At C7-T1, no spinal canal or neural foraminal narrowing is seen.
THORACIC SPINE MRI: Bone marrow signal is diffusely abnormal, low on
precontrast T1 weighted images with heterogeneous high signal on
fat-suppressed IDEAL and postcontrast T1 weighted images, consistent with
diffuse metastatic infiltration.
Mild anterior wedge compression of T9 vertebral body is unchanged compared to
___.
Deformity in the posterior aspect of the T10 superior endplate, likely
secondary to a metastasis, appears larger than on the ___ CT, but this
could be secondary to differences in modalities.
Mild anterior wedging of T12 vertebral body is unchanged since ___.
There is no evidence for an epidural mass. There is no pathologic
leptomeningeal contrast enhancement.
There are small disc protrusions at several thoracic levels, include a T5-T6,
T6-T7, T9-T10, and T10-T11, which do not contact the spinal cord. Evaluation
of spinal cord signal is limited by motion artifact and large field of view on
sagittal images, as well as by the large field of view on axial images, but
cord signal appears normal on axial images.
LUMBAR SPINE MRI: Bone marrow signal is diffusely abnormal, including within
the visualized upper sacrum and medial iliac bones, low on precontrast T1
weighted images with heterogeneous high signal on fat-suppressed IDEAL and
postcontrast T1 weighted images, consistent with diffuse metastatic
infiltration.
Mild L3 and L4 superior endplate deformities are unchanged since ___.
There is no evidence for an epidural mass. There is no pathologic
leptomeningeal contrast enhancement. The conus medullaris demonstrates normal
morphology and signal intensity, terminating at L1.
At T12-L1, there is no spinal canal or neural foraminal narrowing.
At L1-L2, there is a mild disc bulge without spinal canal or neural foraminal
narrowing.
At L2-L3, there is a mild disc bulge and minimal facet arthropathy without
spinal canal or neural foraminal narrowing.
At L3-L4, there is a mild disc bulge and minimal facet arthropathy without
spinal canal narrowing. There is mild bilateral neural foraminal narrowing
without neural impingement.
At L4-L5, there is a mild disc bulge and mild facet arthropathy without spinal
canal narrowing. There is mild bilateral neural foraminal narrowing without
neural impingement.
At L5-S1, there is a mild disc bulge, mild to moderate right and mild left
facet arthropathy. There is no spinal canal narrowing. There is mild to
moderate bilateral neural foraminal narrowing without evidence for neural
impingement.
In the right upper gluteal subcutaneous fat, there is a 15 mm circumscribed
oval structure, included on axial images only, which demonstrates low signal
on T2 weighted images and high signal on postcontrast T1 weighted images
(12:35, 19:35). It is stable in size compared to the ___ CT, on which
it demonstrated mixed fat and soft tissue density. Fat density is not typical
for metastasis. Its clinical significance is uncertain.
IMPRESSION:
1. Diffusely abnormal bone marrow signal in the cervical, thoracic, and lumbar
spine, as well as included upper sacrum and medial iliac bones, indicating
diffuse metastatic disease.
2. Mild loss of height involving several cervical and thoracic vertebral
bodies is noted, unchanged in the thoracic spine compared to the ___
torso CT. No prior cervical spine imaging for comparison.
3. No evidence for epidural or leptomeningeal metastatic disease.
4. Multilevel cervical degenerative disease with moderate spinal canal
stenosis and moderate to severe neural foraminal narrowing.
5. Mild thoracic and lumbar degenerative disease without evidence for neural
impingement.
6. Stable 15 mm oval nodule in the right upper gluteal subcutaneous soft
tissues, of uncertain clinical significance given partial fat density on the
prior CT, but no evidence for fat on the present MRI on which it is
incompletely evaluated.
Radiology Report
INDICATION: ___ year old woman with breast cancer metastatic to bone
presenting with likely progression of disease. // Staging/survey for
metastatic disease
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Stationary Acquisition 19.4 s, 0.2 cm; CTDIvol = 330.0 mGy (Body) DLP =
66.0 mGy-cm.
5) Spiral Acquisition 6.0 s, 70.6 cm; CTDIvol = 3.8 mGy (Body) DLP = 247.5
mGy-cm.
6) Spiral Acquisition 2.5 s, 32.1 cm; CTDIvol = 3.5 mGy (Body) DLP = 97.0
mGy-cm.
Total DLP (Body) = 412 mGy-cm.
COMPARISON: CT abdomen pelvis 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: Of the 3 hypodense liver lesions previously identified, only 2
are currently appreciated (05:51, 54). The remainder the liver is
homogeneous. The portal vein is patent. The gallbladder is within normal
limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: There is stable thickening of the left adrenal gland, and normal
appearance of the right adrenal gland.
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 is decompressed. The uterus is normal. The ovoid
soft tissue structure in the left adnexa, separate from the left ovary, is
essentially unchanged in size, now measuring 3.7 x 2.5 cm (5:98), previously
4.0 x 2.7 cm in ___. There is no pelvic lymphadenopathy or free fluid in the
pelvis.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: As with the prior study from ___, there is diffuse sclerosis of the
skeleton in keeping with metastatic disease. There is no compression
deformity in the lumbar spine. There is a tiny chip fracture at the posterior
wall of the right acetabulum (5:100), which has sclerotic borders, suggesting
nonacute nature but new from ___. No other pelvic fractures
appreciated.
SOFT TISSUES: There is a peripherally calcified soft tissue structure within
the right iliacus muscle measuring 1.9 x 1 cm (5:94), and may be a sequela of
trauma. This is not have the appearance of and intramuscular metastasis.
There is a soft tissue nodule in the subcutaneous fat of the left lower back
(5:76), which was not seen on the prior study. Correlation with injection
therapy is recommended. No other soft tissue lesions are appreciated.
IMPRESSION:
1. Of the 3 previously identified hypodense liver lesions, only 2 are seen,
relatively similar in size. Interval stability is reassuring however not
diagnostic for a benign process.
2. Stable thickening of the left adrenal gland.
3. Stable soft tissue mass in the left adnexa, of unclear etiology.
4. Diffuse osseous metastases. No compression deformities in the lumbar
spine.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Metastatic breast cancer. Restaging.
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 compared to chest CT scanning since ___.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
4) Stationary Acquisition 19.4 s, 0.2 cm; CTDIvol = 330.0 mGy (Body) DLP =
66.0 mGy-cm.
5) Spiral Acquisition 6.0 s, 70.6 cm; CTDIvol = 3.8 mGy (Body) DLP = 247.5
mGy-cm.
6) Spiral Acquisition 2.5 s, 32.1 cm; CTDIvol = 3.5 mGy (Body) DLP = 97.0
mGy-cm.
Total DLP (Body) = 412 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: ___.
FINDINGS:
The imaged thyroid gland is homogeneous. There are no pathologically enlarged
mediastinal, hilar, or axillary lymph nodes. Surgical clips are noted in the
right axilla, likely from prior lymph node dissection. Heterogeneity of the
left breast tissue is noted, of unclear etiology.
The esophagus is normal in course and contour. Heart size is normal and there
is no pericardial effusion. No pleural effusion is appreciated. No
pneumothorax.
The lungs demonstrate scattered areas of subpleural scarring. Previously
identified areas of ground-glass in the left upper lobe and right upper lobe
have resolved. No concerning nodules or areas of consolidation.
Heterogeneous appearance of the a entire thoracic spine is indicative of
diffuse osseous metastasis, which is similar in appearance to the CT from ___. No compression deformities in the thoracic spine to suggest
pathologic fracture. Additionally, there are numerous sclerotic rib lesions
bilaterally as well as healed fractures. The sternum and manubrium
demonstrate heterogeneous density, indicative of metastatic involvement.
IMPRESSION:
1. No evidence of metastatic disease to the pleura, mediastinum, or pulmonary
parenchyma.
2. Numerous osseous metastases, not significantly changed from ___,
and no pathologic compression deformity in the thoracic spine or acute
pathological rib fractures.
3. Previously identified areas of ground-glass in the upper lobes bilaterally
have resolved since the prior study.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.2
heartrate: 83.0
resprate: 14.0
o2sat: 100.0
sbp: 119.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ with metastatic breast cancer, blindness ___ congenital
glaucoma, depression, and asthma referred from ___'s office for
subacute mental status decline and increasing falls, confusion,
and dysarthria at home.
# Falls/Instability: Patient presented with poor cerebellar exam
and 'shaking'. CT scan showed no acute lesions. MRI was degraded
by with significant movement artifact but showed no evidence of
direct CNS involvement. ID work-up was negative and she had no
fever or leukocytosis. Repeat MRI head with no clear intraxial
mets but calvarial lesions consistent with bony metastases. MRI
C/T/L spine with and without contrast showed cervical spine
stenosis and e/o bony mets but no intramedullary lesions.
Neurology was consulted given her ataxia and felt that her
symptoms were concerning for a possible paraneoplastic syndrome.
Serologies were sent but did not return until after discharge.
Patient was noted to be B12 deficient as a possible cause and
repleted during hospitalization. Patient worked with physical
therapy daily and had improvement in gait though still was
notable to be a significant fall risk.
- f/u serologies.
- f/u with neurology as an outpatient
- please check B12 and replete as needed.
# Subacute Right Acetebular Fracture: Likely pathological. Seen
by Orthopaedics with no plans for surgery at this time give
patient's frail state. Recommended plan below:
- Activity: Protected weight bearing until further notice - may
weight bear as pt is able but she must do so with a walker.
- ___ as patient can tolerate, encourage ambulation
- Defer R hip surgery until further notice.
- Follow-up with Dr. ___ in ___ ___ clinic in ___ weeks
for reassessment
# DM: Diagnosis of diabetes, previously on medications, no off
for several months after losing weight. Placed on HISS to
control sugars.
- discharged to rehab on ___, recommend transition to oral
medication (metformin)
# Metastatic breast cancer: Patient with numerous bony
metastases and rising ___. Holding chemotherapy at this
time. Will followup with Dr. ___.
# Asthma: continued symbicort
# Depression: Stable. Continue home Buproprion XL 300mg daily
and Sertraline 200mg daily
# HTN: Continued home atenolol
==================== |
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 distension, weakness, and rectal bleeding
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
Mr. ___ is a ___ y/o male with ESLD ___ HIV/HBV/HCV
(genotype 1b), c/b cirrhosis and varices, also HIV since ___
(with CD4 171 ___, undetectable viral load on HAART),
cryoglobulinemia, SCC of anus s/p excision/XRT (___), asthma,
prior cerebellar infarct and hemorrhage, who now presents with
abdominal distention, weakness, dizziness and rectal bleeding.
He underwent umbilical hernia repair with mesh on ___.
Post-operatively, his course was complicated by cellulitis
around his incisions which were treated with IV Vancomycin and
PO Ciprofloxacin, and transitioned to PO Augmentin. On ___, he
presented to clinic with watery diarrhoea. At that time he was
told to stop antibiotics and collect a specimen for C. diff. He
re-presented on ___ with worsening lower abdominal pain and
persistent diarrhea. He was admitted for further investigation
of c.diff. His stool was positive for C.diff and he was
discharged on ___
with PO flagyl.
After returning home, he had an episode of dizziness, weakness
in his lower limbs and generally feeling lethargic today. His
wife noted that he was now passing fresh blood via his stool,
which had been absent for a period of time. He also complained
of being more bloated. No nausea or vomiting. He was readmitted
for further evaluation.
Since admission, he had nausea/vomiting which was evaluated with
KUB showing gas in scattered non-distended loops of large bowel,
with no fecal loading or dilated air-filled loops of bowel to
suggest obstruction. He was treated with PO vanc/flagyl. He was
evaluated by ___. Orthostatic evaluation at that time was notable
for heart rate increase from 92 to 116 from lying to standing.
He continued to complain of dizziness and L ear fullness. He had
an episode of hypoglycemia to ___ and was transferred to
medicine for further management.
Past Medical History:
1. HIV dx ___. On ART.
2. Squamous rectal cancer ___ tx with excision and radiation
3. HCV genotype 1b, s/p ribavirin and IFN stage ___ fibrosis on
biopsy, grade 2 inflammation, HepC VL: 1,454,840 IU/mL
4. Mild, chronic microvascular ischemic changes and chronic
lacunar infarcts in the R. basal ganglia and R. cebellum; small
chronic infarct in R. cerebellum ___
5. Splenomegaly and small liver cysts; massive splenomegaly on
ultrasound in ___
6. HBV - ___: HBsAG negative, HBsAb positive, HBcAb
positive. ___: HBsAb negative, HBcAb positive.
7. Asthma
8. Lumbar disk disease
9. Surgical repair of umbilical hernia
Social History:
___
Family History:
No CAD, MI, mother with stroke at ___. Father with prostate
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T 97.9, HR 76, BP 114/77, RR 16, Sats 97%RA
Gen: NAD, appears comfortable
CV: RRR, normal S1 and S2, no mumurs, rubs, or gallops
Resp: clear to auscultation bilaterally, good respiratory effort
Abdomen: Abdomen distended, soft to palpate. Palpable
splenomegaly. Wound sites healing well. Abdomen generally
uncomfortable on deep palpation, more significant around
umbilicus. Not peritonitic. No rebound, no guarding.
Ext: Trace edema; 2+ DP and ___ pulses, 2+ radial pulses
bilaterally
PR: Performed by ED. Stool positive guaiac
DISCHARGE PHYSICAL EXAM:
99.3 98.3 118/79 70 18 96RA
I/Os: ___ +3BM
Gen: Lying in bed, NAD
HEENT: Sclera anicteric. Extraocular movements intact. No
lingual asterixis. Neck supple. No LAD.
CV: RRR, S1/S2, no m/r/g
Resp: Clear to auscultation bilaterally. Normal respiratory
effort.
Abdomen: Abdomen distended but non-tense. Soft, tender to deep
palpation. Endorses pain with palpation. Surgical incisions
c/d/i. No rebound tenderness. +BS, +Flatus.
Ext: No edema. 2+ DP pulses
Skin: Chronic-appearing skin changes on anterior shins L>R.
Otherwise no rash noted.
Neuro: Grossly intact, moves all extremities, A/O x3
Pertinent Results:
Labs on Admission:
___ 05:58AM BLOOD Cortsol-9.6
___ 05:58AM BLOOD C3-29* C4-2*
___ 10:40AM BLOOD WBC-3.7* RBC-2.82*# Hgb-9.7*# Hct-26.7*
MCV-95 MCH-34.6* MCHC-36.5* RDW-15.6* Plt Ct-67*
___ 11:35AM BLOOD Neuts-57 Bands-0 ___ Monos-5 Eos-1
Baso-0 ___ Myelos-0 Plasma-1*
___ 04:38AM BLOOD ___ PTT-48.9* ___
___ 04:38AM BLOOD Glucose-103* UreaN-17 Creat-1.3* Na-141
K-3.9 Cl-111* HCO3-28 AnGap-6*
___ 04:38AM BLOOD ALT-59* AST-66* AlkPhos-116 TotBili-0.8
___ 04:38AM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.8 Mg-2.5
Labs on Discharge:
___ 06:00AM BLOOD WBC-4.5 RBC-UNABLE TO Hgb-UNABLE TO
Hct-25.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-46*
___ 05:55AM BLOOD ___ PTT-45.7* ___
___ 05:55AM BLOOD WBC-PND RBC-UNABLE TO Hgb-UNABLE TO
Hct-28.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-PND
___ 05:55AM BLOOD Glucose-110* UreaN-22* Creat-1.4* Na-143
K-4.5 Cl-113* HCO3-26 AnGap-9
___ 05:55AM BLOOD ALT-58* AST-45* AlkPhos-89 TotBili-0.8
___ 05:55AM BLOOD Calcium-9.8 Phos-4.2 Mg-3.1*
CT abd ___:
1. Pancolonic wall thickening with thumbprinting. Findings
concerning for C difficile colitis/ pancolitis.
2. No evidence of obstruction, perforation, or pneumatosis.
3. Cirrhotic liver morphology with findings of portal
hypertension including ascites and massive splenomegaly.
Portable Abdomen KUB ___:
1. No free air. 2. Gasless abdomen. Recommend CT to further
evaluate for possible ileus or obstruction.
ABD US ___:
1. No focal liver lesions to suggest HCC. Hepatopetal flow in
patent portal vein.
2. Coarsened liver with splenomegaly and small amount of
ascites.
Portable Abdomen KUB ___:
Gas seen in scattered non-distended loops of large bowel. No
fecal loading or dilated air-filled loops of bowel to suggest
obstruction is identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Etravirine 200 mg PO BID
4. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID
5. Raltegravir 400 mg PO BID
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. MetRONIDAZOLE (FLagyl) 500 mg PO TID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Etravirine 200 mg PO BID
4. Raltegravir 400 mg PO BID
5. Acetaminophen 500 mg PO Q6H:PRN pain
6. Ipratropium-Albuterol Inhalation Spray 2 INH IH BID
7. Ondansetron 4 mg IV Q8H:PRN N/V
8. Vancomycin Oral Liquid ___ mg PO Q6H
9. Outpatient Lab Work
Please check on ___: Na, K, Cl, HCO3, BUN, Cr, WBC,
Hgb/Hct, Plt.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Recent history of C diff; still on treatment
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Nausea and vomiting, status post umbilical hernia repair complicated
by C. diff, on Flagyl; evaluate ileus, constipation.
ABDOMEN, SINGLE SUPINE PORTABLE VIEW:
Diaphragms not included. The extreme left abdominal wall is excluded from the
film.
No air-filled dilated loops of small or large bowel are detected on the
current examination. Gas is seen in non-dilated portions of much of the small
bowel from the proximal descending colon through the rectum. No dilated
air-filled loops of small bowel are identified. Given the degree of
decompression, it is difficult to assess for any evidence of bowel wall
thickening. Limited assessment for free air on this supine film reveals no
obvious evidence of free air.
Multiple metallic radiodensities overlie the left abdomen, suggestive of BBs.
Targeted review of a ___ abdominal CT from ___ suggests that these lie
in the soft tissues along the lateral chest and upper abdomen posteriorly;
likely BBs.
IMPRESSION: Gas seen in scattered non-distended loops of large bowel. No
fecal loading or dilated air-filled loops of bowel to suggest obstruction is
identified.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with known HCV/HBV/ETOH cirrhosis and increasing
abdominal distention and pain // Please evaluate for ascites, portal vein
thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound of the abdomen from ___ and CT scan of
the abdomen from ___
FINDINGS:
LIVER: The echogenicity of the liver is coarsened. The contour of the liver is
nodular. There is no suspicious focal liver mass. There is a tiny
subcentimetric hepatic cyst in segment VIII. Main portal vein is patent with
hepatopetal flow. There is a small amount of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures mm.
GALLBLADDER: There is no evidence of stones. The gallbladder demonstrates wall
thickening likely related to the patient's chronic liver disease. There is no
gallbladder distension
PANCREAS: Head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity and grossly enlarged, measuring approximately 25
cm.
KIDNEYS: The right kidney measures 12.3 cm. The left kidney measures 13 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. No focal liver lesions to suggest HCC.
2. Coarsened liver with splenomegaly and ascites.
Radiology Report
INDICATION: ___ year old man with abdominal distention and pain, rebound
tenderness // Please assess for SBO, ileus, abd free air
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph from ___
FINDINGS:
Overall there is a paucity of gas in the abdomen. This could be due to
ascites, or bowel loops (either normal caliber or distended, that is filled
with fluid. There is no evidence of intraperitoneal free air.
At least 20 metallic radiodensities are again seen overlying the left lateral
thorax, left upper quadrant and left mid abdomen.
The bony structures are unremarkable.
IMPRESSION:
1. No free air. 2. Gasless abdomen. Recommend CT to further evaluate for
possible ileus or obstruction.
NOTIFICATION: Recommendations communicated with Dr. ___ by Dr. ___ by telephone
at 15:00 on ___.
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous contrast.
INDICATION: ___ year old man with abdominal distention and pain, rebound
tenderness. Previous KUB non-diagnostic. // Please evaluate for
intra-abdominal free air, SBO or anatomic explanation for distention/rebound
tenderness
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
the administration of intravenous contrast.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was administered.
DOSE: DLP: 858.34 mGy-cm (abdomen and pelvis.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST:
There is bibasilar atelectasis. There is no pulmonary nodule or mass in the
visualized lung bases. There is cardiomegaly.
Abdomen/pelvis:
Evaluation of abdominal and pelvic organs is limited due to lack of
intravenous contrast. Liver parenchyma has normal attenuation without evidence
of steatosis. The gallbladder is contracted. There is no intrahepatic or
extrahepatic biliary dilatation. The spleen is markedly enlarged measuring
24.6 cm. The pancreas is grossly unremarkable without evidence of pancreatic
ductal dilatation. Kidneys are symmetric in size and shape without evidence of
hydronephrosis or hydroureter. Urinary bladder is moderately distended with no
gross abnormality.
There is pancolonic bowel wall thickening with thumbprinting. There are no
dilated loops of bowel. There is no evidence of contrast extravasation.
There is no intraperitoneal free air. There is no evidence of pneumatosis.
There is edema throughout the mesentery. There is small amount of perihepatic
and perisplenic ascites as well as a small amount of free fluid in the pelvis.
There are no enlarged inguinal, iliac chain, or retrocrural lymph nodes. There
is mild atherosclerotic calcification of the abdominal aorta. There is no
suspicious osseous lesion.
There are tiny round metallic pellets scattered throughout the posterior left
subcutaneous tissues with a single pellet located within the retroperitoneum
superior to the left kidney. There is unchanged anterior wall
IMPRESSION:
1. Pancolonic wall thickening with thumbprinting. Findings concerning for C
difficile colitis/ pancolitis.
2. No evidence of obstruction, perforation, or pneumatosis.
3. Cirrhotic liver morphology with findings of portal hypertension including
ascites and massive splenomegaly.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with RECTAL & ANAL HEMORRHAGE
temperature: 97.4
heartrate: 74.0
resprate: 18.0
o2sat: 97.0
sbp: 126.0
dbp: 78.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ with HIV since ___ (with CD4 171 ___,
undetectable viral load on HAART), Hep B, Hep C, SCC of anus
treated with excision/XRT (___), asthma, s/p recent umbilical
hernia repair c/b cellulitis, c-diff infection, complaining of
abdominal distension, weakness, dizziness and rectal bleeding.
# Colitis with known C. diff infection:
He had abdominal pain and distention on presentation, and CT
consistent with pan-colitis in the setting of known C. diff.
There was low suspicion for obstruction given imaging findings,
good PO intake and ongoing bowel movements. A flexible
sigmoidoscopy was performed on ___ which showed petechiae
and abnormal vascularity in the rectum, sigmoid colon and distal
descending colon compatible with unspecified colitis. A
diagnostic paracentesis was considered given suspicion for SBP
but deferred due to lack of readily accessible ascites pocket,
lack of signs of systemic infection and slowly improving
abdominal exam.
He was initially treated with vanc/metronidazole and
subsequently narrowed to PO vancomycin (given that metronidazole
can cause abdominal discomfort confounding his exam). After
discharge he will need to complete a course of PO vancomycin
pending clinical response (tentatively will continue vancomycin
until ___ and will reassess clinical symptoms of C. diff that
time).
Given concern for alternate cause of colitis, cold forceps
biopsies were taken of left colon during flexible sigmoidoscopy
and pending at time of discharge; results were pending and will
need follow-up after discharge.
# ___:
He has had slowly worsening renal function over the past 4
weeks. Urine electrolytes were notable for FeNA 0.2%, FeUrea
0.28% suggesting pre-renal etiology in the setting of C.
difficile diarrhea. He improved slightly after albumin. The
differential diagnosis for a second underlying process
contributing to his subacutely worsening renal function remains
broad, and in consultation with nephrology, cryoglobulins were
sent due to concern for cryoglobulin-mediated renal disease.
# Cirrhosis:
___ class B. Likely secondary to ETOH/HBV/HCV.
Decompensated by esophageal varices and coagulopathy, also with
ascites. Was treated for HIV and HCV as below. He was not given
diuretics given ___ and known volume loss from intraabdominal C.
difficile infection.
# Hypoglycemia:
He was noted to have low FSBGs in the ___. He never had symptoms
of hypoglycemia. He has not been using insulin. Venous glucose
has been consistently higher than FSBGs, raising concern for
falsely low values on FSBG possibly due to cryoglobulinemia.
Given this finding, further workup for hypoglycemia was
deferred.
# Thrombocytopenia:
He had chronic thrombocytopenia which has been worse for past 3
months. Likely multifactorial, secondary to splenic
sequestration (known massive splenomegaly >20cm), cirrhosis and
marrow suppression in setting of HIV/HepB/HepC. We continued SC
Heparin for prophylaxis.
# Leukopenia:
He had a history of chronically low WBC since at least ___.
Likely related to chronic viral infections, can pursue
outpatient workup if indicated. Not neutropenic during this
admission.
# Vertigo, gait disturbance:
Followed by outpatient neurology. On previous neurology
assessment, dizziness and imbalance were felt to be likely
multifactorial contributed by prior cerebellar insults,
orthostasis and peripheral neuropathy. Also possibly
contributory hypoglycemia on this admission. Neuro exam with no
new neurologic deficit. He was evaluated by physical therapy who
recommended rehab placement due to gait instability with a
rolling walker.
# BRBPR:
Hct remained stable and near baseline. His history of BRBPR was
most likely secondary to known internal hemorrhoids, seen on
colonoscopy in ___. Also had EGD from ___ which showed varices
at the distal esophagus, congestive gastropathy. He had no
active bleeding during this admission.
# Cryoglobulinemia: He likely has mixed cryoglobulinemia in
setting of chronic HCV infection. HBV and HIV were also noted to
be associated with cryoglobulinemia. With regard to symptoms, he
has known peripheral neuropathy but no palpable purpura.
Treatment would include immunosuppression and treatment of
underlying viral infections. CNS vasculitis from cryoglobulins
can manifest as stroke. However unclear that cryoglobulinemia is
driving his symptomology at this time. C3, C4 very low this
admission. CBC tubes were placed in warm water and taken
immediately to lab. He had cryoglobulin level pending at
discharge which will need follow-up after discharge.
# HIV: On treatment. Viral load undetectable, CD4 count was 247
in ___. Renally dosed HIV meds.
# HCV: S/P treatment in past (s/p ribavirin and IFN) but last
viral load in ___ over 1,000,000. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Aspirin / Sudafed / Toradol / Levaquin / iv contrast /
Amitriptyline / Motrin / Ultram / acetaminophen / latex tape
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male initially admitted to the medical service two
days
ago with complaints of shortness of breath and abdominal pain.
The shortness of breath improved but the abdominal pain did not
and he was not having bowel movements or passing gas. See
admission note/ACS consult note from ___ for full details. In
brief, however, he was transferred to the ACS service in the
evening of the day of his admission (yesterday) for management
of
his SBO. He was scheduled to have a CT Chest to rule out a PE
given his prior history of PE and not being on anticoagulation
and was going premedication.
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
- ? Mental Retardation
-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:
Exam upon admission: ___:
99.6 77 148/82 18 95RA
NAD, AAOx3
RRR
unlabored respirations
abdomen distended, tender to palpation diffusely to moderate
palpation - similar in exam to prior, urostomy appears healthy
and functional
extremities warm
Pertinent Results:
___ 07:50PM BLOOD Plt ___
___ 07:50PM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-133
K-4.8 Cl-97 HCO3-22 AnGap-19
___ 07:50PM BLOOD ALT-12 AST-33 AlkPhos-75 TotBili-0.2
___ 08:02PM BLOOD Lactate-4.6*
___: CT abd. and pelvis:
1. The stomach is severely distended and multiple mildly dilated
loops of
proximal small bowel are fluid-filled concerning for partial
obstruction.
2. Mild left hydronephrosis is likely chronic.
3. An ileal conduit urostomy is again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine extended-release 800 mg PO QHS
2. Fentanyl Patch 25 mcg/h TD Q72H
3. Morphine Sulfate ___ ___ mg PO BID:PRN Pain - Severe
4. TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
no prescriptions provided, the patient left the hospital against
medical advice.
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
small bowel obstruciton
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest and CT abdomen and pelvis
INDICATION: ___ year old man with prior history of PE, with shortness of
breath, equivocal Wells score, not on anticoagulation, also has SBO// please
assess for PE. Needs premedication prior given past IV contrast allergy.
Please scan abdomen to assess for SBO, does not need to be CTA protocol for
abdomen.**WILL BEGIN PRE-MED AT 5AM, PLEASE SCHEDULE STUDY FOR 10AM (DISCUSSED
WITH O/N RADIOLOGIST + TECH)
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 7.2 mGy (Body) DLP = 271.8
mGy-cm.
2) Spiral Acquisition 2.9 s, 46.7 cm; CTDIvol = 10.3 mGy (Body) DLP = 481.3
mGy-cm.
3) Spiral Acquisition 0.7 s, 10.7 cm; CTDIvol = 9.0 mGy (Body) DLP = 96.3
mGy-cm.
4) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 13.8 mGy (Body) DLP =
6.9 mGy-cm.
Total DLP (Body) = 856 mGy-cm.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection. There
is mild atherosclerotic calcification of the aortic arch. There is no
penetrating atherosclerotic ulcer. The heart is normal in size. There is no
evidence of right heart strain. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There are numerous nonenlarged mediastinal
lymph nodes, measuring up to 8 mm in short axis, likely reactive secondary to
underlying lung disease. There is no mediastinal mass. There are also
nonenlarged bilateral hilar lymph nodes.
PLEURAL SPACES: There is no pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There extensive panlobular emphysema. There is mucous plugging
of the right upper lobar bronchus and proximal segmental branches. There is a
calcified granuloma in the medial left upper lobe. There is no pulmonary mass
or suspicious nodule. There is scattered subsegmental atelectasis of the
bilateral lower lobes, right middle lobe and lingula.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver is normal in size and homogeneous attenuation. No
focal hepatic lesion is detected. The gallbladder is within normal limits.
There is no intra- or extrahepatic biliary ductal dilatation.
PANCREAS: The pancreas is homogeneous in attenuation, without evidence of
focal lesion or main ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is normal in size and homogeneous in attenuation.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys demonstrate normal nephrograms. There are surgical clips
in the medial interpolar region of the left kidney. There are areas of
cortical scarring in the both kidneys, left worse than right. There is mild
left hydronephrosis, with a transition point in the mid ureter, obscured by
streak artifact from multiple retroperitoneal clips, slightly worsened
compared to the prior CT from ___. There is no right
hydronephrosis. There is no perinephric abnormality. There are postsurgical
changes of cystectomy with right lower quadrant ileal conduit.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops are normal
in caliber, with resolution previously seen partial small bowel obstruction on
CT of the abdomen/pelvis from ___. The colon is distended with gas
and stool. The rectum is within normal limits. There is no free
intraperitoneal fluid or free air.
PELVIS: There is no free fluid in the pelvis. There is no pelvic or inguinal
lymphadenopathy.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no mesenteric or retroperitoneal lymphadenopathy. There
are multiple retroperitoneal clips from prior lymph node dissection.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. The major mesenteric branch vessels are patent.
BONES AND SOFT TISSUES: There is no suspicious osseous lesion or acute
fracture.
IMPRESSION:
1. No evidence of pulmonary embolism to the level of the subsegmental
arteries. No acute pulmonary parenchymal process.
2. Mild left hydronephrosis, with a transition point in the mid ureter,
obscured by streak artifact from multiple retroperitoneal clips, unchanged
compared to the prior CT from ___.
3. Interval resolution of previously seen partial small bowel obstruction on
CT of the abdomen/pelvis from ___.
4. Postsurgical changes of cystectomy with right lower quadrant ileal conduit.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified intestinal obstruction
temperature: 99.6
heartrate: 78.0
resprate: 18.0
o2sat: 95.0
sbp: 149.0
dbp: 82.0
level of pain: 10
level of acuity: 2.0 | ___ year old male who was admitted to the medical service with
shortness of breath and abdominal pain. The shortness of breath
improved but the abdominal pain continued. He was not having
bowel movements or passing gas. The patient underwent a cat
scan of the abdomen on ___ which showed a distended stomach and
mildy dilated loops of proximal small bowel concerning for
partial obstruction. The patient was transferred to the Acute
Care service for management of his SBO. He was made NPO, and
given intravenous fluids. He refused placement of a
___ tube. On ___, he refused further medical care and
removed his intravenous line. The importance of continued
medical care for his safety and well-being were addressed. The
patient left the hospital against medical advice. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / morphine / digoxin /
lisinopril / Dilaudid
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
___ s/p right hip incision and drainage and washout
History of Present Illness:
Ms. ___ is a ___ woman with a past medical history
of atrial
fibrillation s/p PVI in ___ and ___, HTN, HLD, who presents with
severe RLE pain.
The patient underwent PVI on ___ via ___ and ___ L femoral
sheaths and 8.5F R femoral sheath. Post-procedure, the patient
felt unwell, with headache and nausea. On day of this admission,
she developed severe RLE pain, limiting her ability to ambulate.
She has not previously experienced pain of such severity.
The patient denies CP, SOB, fever, chills, or subsequent RLE
trauma. A full 10 point review of systems was reviewed and is
otherwise negative in detail
Past Medical History:
Recurrent atrial fibrillation/flutter on warfarin; PVI ___ hx
of RVR/atrial tachycardia; s/p CV x3; failed propafenone and
amiodarone;
Hypertension
Hyperlipidemia
Hx of DVT - patient denies
Appendectomy
Social History:
___
Family History:
Positive family history of atrial arrythmias: Son (deceased
following PVI), brother
Physical ___ physical exam: VS: 98.0, 73, 129/69, 16, 98% RA
General/Neuro: Comfortable lying flat, significant
discomfort R inner upper groin with any RLE movement. NAD. LAert
and oriented. Nonfocal.
Cardiac: RRR [X] Irregular [] Nl S1 S2
Lungs: CTA [X] No resp distress [X]
Abd: NBS [X]Soft [X] ND [] NT [X]
Extremities: trace edema [X] ___: doppler [] palpable [X]
Severe ttp in R groin and extending medially to knee. ROM
limited by pain. 2+ femoral and DP pulses. Strength ___ in
distal
RLE. No bruit, erythema, swelling, warmth or ecchymosis in RLE.
Access Sites: CDI [X] no bleeding, ecchymosis or hematoma
Discharge physical exam:
Gen: Patient with mild discomfort with movement, cooperative.
Pain in
right hip area improving
HEENT: Face symmetrical, trachea midline.
Neuro: A/Ox3. Speaking in complete, coherent sentences. Smile
symmetric. MAE equal and strong, strong ___ hand grasps, and L
foot pushes; R foot push weaker than L.
Pulm: Breathing unlabored. Lungs clear bilaterally.
Cardiac: No JVD. S1, S2 RRR. No murmurs, friction rubs heard.
Abd: Rounded, soft, non-tender.
Vasc: Mild edema in right upper thigh> left. Mild tenderness to
inner right thigh with palpation. No pigmentation changes noted
in bilateral upper or lower extremities. Skin dry, warm.
Bilateral radial, ___ pulses palpable 2+.
Right hip with intact dressing-changed by ortho (___), CDI.
No hematoma.
Pertinent Results:
Admit labs:
___ 04:14PM BLOOD WBC-7.4 RBC-4.23 Hgb-13.2 Hct-39.5 MCV-93
MCH-31.2 MCHC-33.4 RDW-14.5 RDWSD-49.7* Plt ___
___ 04:14PM BLOOD Neuts-72.2* Lymphs-10.1* Monos-16.2*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-5.32 AbsLymp-0.74*
AbsMono-1.19* AbsEos-0.05 AbsBaso-0.02
___ 04:14PM BLOOD ___ PTT-34.2 ___
___ 04:14PM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-138 K-4.5
Cl-97 HCO3-23 AnGap-18
___ 04:14PM BLOOD CRP-217.1*
___ 11:43PM BLOOD Lactate-0.8
___ 12:45PM JOINT FLUID ___ RBC-7000* Polys-97*
___ Macro-2
RIGHT HIP MUSCLE HEMATOMA.
GRAM STAIN (Final ___ 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Discharge labs:
___ 05:41AM BLOOD WBC-9.3 RBC-2.16* Hgb-6.6* Hct-20.2*
MCV-94 MCH-30.6 MCHC-32.7 RDW-15.0 RDWSD-51.7* Plt ___
___ 04:30PM BLOOD Hgb-9.4* Hct-28.6*
___ 04:28AM BLOOD Neuts-80.8* Lymphs-6.6* Monos-11.2
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.09* AbsLymp-0.74*
AbsMono-1.26* AbsEos-0.08 AbsBaso-0.03
___ 05:41AM BLOOD Glucose-103* UreaN-31* Creat-2.0* Na-136
K-4.8 Cl-99 HCO3-27 AnGap-10
___ 05:41AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1
___ 05:41AM BLOOD CRP-163.2*
INRs
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Amiodarone 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Warfarin 2.5 mg PO 6X/WEEK (___)
6. Warfarin 5 mg PO 1X/WEEK (WE)
7. melatonin 10 mg oral QHS: PRN
8. Psyllium Powder 1 PKT PO TID:PRN supplement
9. Vitamin D 1000 UNIT PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral unk
11. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. CeFAZolin 2 g IV Q12H
Please take this antibiotic until ___
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Pantoprazole 40 mg PO Q24H
7. TraMADol 50 mg PO Q6H:PRN pain
8. Amiodarone 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral unk
11. Cetirizine 10 mg PO DAILY
12. melatonin 10 mg oral QHS: PRN
13. Multivitamins 1 TAB PO DAILY
14. Psyllium Powder 1 PKT PO TID:PRN supplement
15. Simvastatin 20 mg PO QPM
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 5 mg PO 1X/WEEK (WE)
18. Warfarin 2.5 mg PO 6X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right psoas abscess and septic hip arthritis
Hypertension
Hyperlipidemia
Atrial fibrillation status post PVI ×2, last ___
Acute kidney injury
Discharge Condition:
Vital signs: 98.4, BP 116-142/68-83, HR 71-78, RR ___, Sats
94-98% RA
Weight on discharge: 75.8kg/167.1lb
Physical Examination:
Gen: Patient with mild discomfort with movement, cooperative.
Pain in
right hip area improving
HEENT: Face symmetrical, trachea midline.
Neuro: A/Ox3. Speaking in complete, coherent sentences. Smile
symmetric. MAE equal and strong, strong ___ hand grasps, and L
foot pushes; R foot push weaker than L.
Pulm: Breathing unlabored. Lungs clear bilaterally.
Cardiac: No JVD. S1, S2 RRR. No murmurs, friction rubs heard.
Abd: Rounded, soft, non-tender.
Vasc: Mild edema in right upper thigh> left. Mild tenderness to
inner right thigh with palpation. No pigmentation changes noted
in bilateral upper or lower extremities. Skin dry, warm.
Bilateral radial, ___ pulses palpable 2+.
Right hip with intact dressing-changed (___), CDI. No
hematoma.
=========================
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: FEMORAL VASCULAR US RIGHT
INDICATION: ___ year old woman with recent PVI, now with right groin pain.
Evaluation for pseudoaneurysm vs. hematoma
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right groin in the area patient's discomfort.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right groin in the area of patient's discomfort. No pseudoaneurysm
identified. Common femoral artery and vein demonstrate normal waveforms
without evidence for fistula. In the superficial soft tissues lateral to the
common femoral vasculature, there is a focal hypoechoic fluid collection
measuring 0.9 x 2.3 x 0.7 cm, likely compatible with a hematoma.
IMPRESSION:
1. No pseudoaneurysm or arteriovenous fistula identified.
2. Focal hypoechoic fluid collection in the superficial soft tissues lateral
to the vasculature measures 0.9 x 2.3 x 0.7 cm, likely compatible with a
hematoma.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with recent PVI, now with right groin pain.
Evaluation 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.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: CTA PELVIS WANDW/O C AND RECONS
INDICATION: ___ year old woman with recent PVI for AF, now with right groin
pain// Please evaluate for dissection vs. hematoma
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 8.5 s, 67.1 cm; CTDIvol = 5.2 mGy (Body) DLP = 348.5
mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 24.3 mGy (Body) DLP =
12.1 mGy-cm.
3) Spiral Acquisition 8.6 s, 67.3 cm; CTDIvol = 13.7 mGy (Body) DLP = 923.8
mGy-cm.
4) Spiral Acquisition 8.6 s, 67.3 cm; CTDIvol = 13.7 mGy (Body) DLP = 921.1
mGy-cm.
Total DLP (Body) = 2,206 mGy-cm.
COMPARISON: Prior ultrasounds from ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is no active extravasation
identified on this exam. There is moderate calcium burden in the abdominal
aorta and great abdominal arteries.
URINARY: Partially visualized kidneys demonstrate left interpolar renal
cortical thinning. No mid to lower pole nephrolithiasis is seen. There is no
hydronephrosis.
GASTROINTESTINAL: Partially visualized loops of small and large bowel
demonstrate no small bowel obstruction. Large bowel demonstrates multiple
diverticula without surrounding inflammation to suggest diverticulitis.
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 bilateral uterus and adnexae are within normal
limits.
BONES/SOFT TISSUES: There is 4.5 x 1.6 x 1.9 cm (series 5; image 89, series
601; image 43) hypodensity within the right iliopsoas muscle with surrounding
stranding in the right groin. Additionally, there is a right hip joint
effusion with surrounding stranding. Underlying septic arthritis cannot be
excluded. These findings are worrying for intramuscular infection with
extension into the joint. There is no right groin hematoma. There is no
active extravasation of contrast.
IMPRESSION:
4.5 x 1.6 x 1.9 cm hypodensity within the right iliopsoas muscle with
surrounding stranding and extension into the right hip joint with small right
hip joint effusion could be secondary to an evolving hematoma. Superimposed
infectious process cannot be excluded as findings could be seen in the setting
of an intramuscular abscess with possible extension into the joint.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/___
INDICATION: ___ year old woman with R hip pain, CT + for stranding and
extension into the right hip joint with small right hip joint effusion// ? of
right hip and/or psoas abscess vs septic arthritis.
COMPARISON: CT ___
TECHNIQUE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
5 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a 18-gauge spinal needle was advanced into the right
hip joint. The hip joint was aspirated and 3 cc of yellow fluid was
successfully removed. The fluid was sent to pathology in a purple top tube
and a 20 cc syringe.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications or complaints.
FINDINGS:
3 cc of yellow fluid was successfully aspirated from the hip joint. Mild joint
space narrowing and bony spurring at the superior hip joint is noted. No
suspicious osseous lesion, fracture or dislocation on limited assessment.
IMPRESSION:
Technically successful fluoroscopic aspiration of the right hip joint.
Specimens were taken to pathology following the procedure.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R SL Power PICC 40cm ___
___ Contact name: ___: ___ R SL Power PICC 40cm ___ ___
IMPRESSION:
No prior chest radiographs available.
New right PIC line ends in the low SVC. Lungs clear. Heart size top-normal.
No pleural abnormalities.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with AF, s/p PVI complicated by right hip
arthritis, now with ___ and ___ creatnine// evaluate for acute
process/obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 11.1 cm
Left kidney: 10.2 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Inguinal pain, Weakness
Diagnosed with Postproc hematoma of skin, subcu following other procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 98.0
heartrate: 73.0
resprate: 16.0
o2sat: 98.0
sbp: 152.0
dbp: 70.0
level of pain: 10
level of acuity: 2.0 | ___ PMH atrial fibrillation s/p PVI in ___ and ___, HTN, HLD,
?h/o DVT, who presents with severe RLE pain with possible psoas
abscess and septic hip arthritis s/p right hip aspiration and
washout by ortho.
# Right psoas abscess and septic hip arthritis: S/p ___ guided
aspiration of the hip joint ___. Joint fluid analysis showed
Staph Lugdunensis which is oxacillin susceptible. Blood cultures
with no growth. S/p right hip wash out by ortho on ___.
Resumed heparin gtt and warfarin. Heparin gtt discontinued ___,
INR therapeutic since.
- Ortho recs: Weight bearing as tolerated. Appointment booked
for staples removal on ___, at 1240 pm. Call ___
with any appointment related concerns.
- ID rec: Continue IV Cefazolin until ___. ID recommends
continuing current cefazolin regimen (2 gm IV Q12) for CrCL<30.
If CrCL >30, increase Cefazolin to 2 gm Q8 hour regimen. ___
clinic manager (___) will call nursing facility with
specific instructions on lab draws per Dr. ___ (ID
fellow). OPAT number is ___ for any
appointment/antibiotic related concerns
- Continue warfarin per home regimen. INR today 3.0 -> reduced
dose of Coumadin 1 mg given. Have INR checked ___ times a week
in rehab. Goal INR ___. Once discharged from rehab, can follow
up with Dr. ___ in ___ Internal Associates, ___ for
regular INR checks.
- Pain management with standing PO Tylenol, PRN, tramadol,
lidocaine patch, and gabapentin and ice
- ___ daily
# ___, probably multifactorial - volume depletion in the
last few
days. Cr improved to 2.0 today, downtrending. Renal ultrasound
normal. CrCL ___ today.
- Renally dose medications
- Continue cefazolin at current regimen. If CrCL >30, increase
the Cefazolin dose to 2 gm Q8 hours.
# Right hip pain: Improving since washout and titrating pain
medications.
- Continue scheduled Tylenol, lidocaine patch, Gabapentin and
PRN tramadol
- Ice packs for comfort PRN
# S/p recent PVI ___: Not on PPI prophylaxis. Was started on
Carafate s/p PVI on ___ that was discontinued on ___ per OMR
record due to headaches and GI upset.
- Continue newly added Pantoprazole until seen in follow up
with ___
- Continue amiodarone 100 daily at least for a month until seen
in the clinic by Dr. ___.
# PROPHYLAXIS:
- DVT prophylaxis with: warfarin
- Pain management with: Tylenol, gabapentin, lidocaine patch
and PRN tramadol.
- Bowel regimen with: Senna/Miralax
# Emergency contact: ___, daughter in law, ___
# Family/HCP updated? Yes
# Code status: Full (presumed)
# DISPO: Rehab tomorrow pending bed availability. Case
management on board, will have bed available on ___ on
___ tomorrow.
# Transitional issues: IV cefazolin for 4 weeks until ___.
PICC line in place. Follow with EP, Ortho and ID as scheduled.
[x] Plan discussed and reviewed with Dr. ___
[x] Plan discussed Ms. ___, and her family, who appear to
understand and agree to proceed with the outlined treatment
plan. All questions answered to apparent satisfaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hypothyrroidism presents with chest pain x 1 day.
A few weeks prior he was in his USOH when he developed a sore
throat that mostly resolved over the course of a week. Last
night he developed chest pain, substernal, that did not
alleviate with rest or position and impaired his ability to
sleep. He presented to BI-Miltion this next morning where an EKG
was done that showed diffuse ST elevation except in AVR, and he
was started on as heparin gtt, aspirin and atorvastatin before
transfer to ___. Of note he had a ESR of 30 drawn at
___.
In the ED, initial vitals were: 99.7 101 122/82 25 98% RA
- Labs were significant for WBC of 12 and Trop negative x 2.
- CXR revealed mild cardiomegaly; Echo revealed a moderate
pericardial effusion.
- The patient was given colchicine 1.2mg, ketorlac ___ IV,
morphine, oxycodone and ibuprofen.
Upon arrival to the floor, he states that the chest pain is
diminished but still present and increasing as the pain
medications given in the ED wear off.
He has no family history of autoimmune diseases, has never been
incarcerated, homeless, or spent significant time in a TB
endemic country.
Past Medical History:
Hypothyroidism
Umbilical Hernia Repair
Social History:
___
Family History:
No history of autoimmune diseases.
Physical Exam:
ADMISSION
Vitals:99.2 94 139/77 16 97% 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; possible small rub
appreciated with systole.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE
Pertinent Results:
ADMISSION LABS
___ 11:40AM BLOOD WBC-12.1* RBC-4.75 Hgb-13.9 Hct-40.2
MCV-85 MCH-29.3 MCHC-34.6 RDW-13.3 RDWSD-41.0 Plt ___
___ 11:40AM BLOOD Neuts-71.8* Lymphs-13.4* Monos-13.7*
Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.64* AbsLymp-1.62
AbsMono-1.65* AbsEos-0.05 AbsBaso-0.04
___ 11:40AM BLOOD ___ PTT-61.5* ___
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-118* UreaN-12 Creat-0.7 Na-136
K-4.4 Cl-100 HCO3-22 AnGap-18
___ 11:40AM BLOOD cTropnT-<0.01
___ 06:10PM BLOOD cTropnT-<0.01
___ 11:40AM BLOOD TSH-3.3
___ 11:40AM BLOOD CRP-13.2*
___ 11:48AM BLOOD Lactate-1.3
IMAGING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
2. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
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: ___ man with chest pain and dyspnea.
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
There is no focal lung consolidation. There is no pneumothorax or pleural
effusion. There is no pulmonary edema. Heart is mildly enlarged. No acute
osseous abnormality.
IMPRESSION:
Mild cardiomegaly. Otherwise, unremarkable chest radiograph.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with PERICARDIAL DISEASE NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ with hypothyroidism presenting with signs, symptoms, and
imaging consistent with pericarditis.
#Pericarditis
Patient had positional chest pain, a small pericardial effusion,
elevated ESR, and preceding history of sore throat consistent
with viral pericarditis. There was no evidence of tamponade on
VS or echo and no history consistent with TB or autoimmune
disease. He was started on colchicine 0.6mg BID to be continued
for 3 months and ibuprofen 800mg TID to be taken for ___ weeks.
CRP on discharge = 13.2. Patient will need to follow up with
PCP and cardiology and have repeat TTE in one month.
#Hypothyroidism
Previously on levothyroxine 50mcg but told to stop 1 month
prior. TSH 6 at ___, FT4 0.8, qualifying as subclinical
hypothyroidism. Has had some fatigue recently, but difficult to
tease out whether due to viral infection. Thyroid function will
need to be reassessed as outpatient and potentially restart
levothyroxine at that time.
Transitional Issues
- New medications: colchicine, ibuprofen
- Recheck CRP in ___ weeks to assess for resolution
- Thyroid function tests as outpatient after resolution of
pericarditis
- Patient with moderate pericardial effusion on admission,
should have repeat TTE in 1 month |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / tramadol / Vicodin
Attending: ___
Chief Complaint:
right face and arm numbness, transient facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while
on chemo, HTN, HL, presents with 1 hour of right face and arm
numbness; initially also with slight right facial droop. Pt was
sitting on a train when she noted the sudden onset of numbness
and tingling in her arm that moved up her face. NO leg
paresthesias and no weakness. When she arrived home symptoms
had improved although when she looked in the mirror and when her
husband looked at her, they felt like there was a slight
asymmetry to her lips and nasolabial folds. Numbness in the face
persists; she describes it as tingling or prickling kind of
numbness, like the feeling after one has been given novocain at
the dentist's, and it's starting to wear off. The numbness in
the arm the pt did not notice herself until it was brought to
her attention by the pinprick exam.
___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while
on chemo, HTN, HL, now with 1 hour of R face/arm numbness;
initially also with slight R droop but this has almost
completely gone away, although when pt looks in mirror, and when
husband looks at her, they still feel like there is a slight
asymmetry to her lips and nasolabial folds. Numbness in the face
persists; she describes it as tingling or prickling kind of
numbness, like the feeling after one has been given novocain at
the dentist's, and it's starting to wear off. The numbness in
the arm the pt did not notice herself until it was brought to
her attention by the pinprick exam. Fingerstick glc 114 on
arrival.
ROS: Yesterday pt had a headache but not currently, and she has
been feeling somewhat unwell for the last week, with malaise URI
symptoms
On neurologic review of systems, the patient denies
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
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 palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
The patient presented with a T2, N0 ER negative/PR negative,
HER-2/neu negative invasive breast cancer diagnosed by biopsy
performed on ___. A sentinel lymph node biopsy performed
on ___ was negative. The patient proceeded with
three cycles of neoadjuvant cisplatin and Avastin given on the
___ protocol. The patient came off the study in ___ when she was diagnosed with a pulmonary embolus. In ___,
the patient underwent a right skin sparing mastectomy and first
stage immediate reconstruction with
placement of a tissue expander. Pathology noted a 1.8 cm
invasive
ductal carcinoma, grade III.
- started adjuvant chemotherapy with doxorubicin and
cyclophosphamide, with the first cycle administered on ___. The patient is receiving this treatment in a
dose-dense regimen. She has completed 4 cycles, every 2 weeks
- Taxol to start ___
.
PAST MEDICAL HISTORY:
====================
asthma
PE
HTN
Social History:
___
Family History:
Breast cancer in mother who was diagnosed at age ___. Her father
had lung cancer and she has one sister who has had a kidney
cancer. No known family history of TIA or stroke at early age.
Physical Exam:
Physical Examination:
VS T:97.4 HR:66 BP:118/77 RR:18 SaO2:100%RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no LAD or thyromegaly
Cardiovascular: No carotid, vertebral or subclavian bruits;
carotids w/ nl volume & upstroke, RRR, no M/R/G
Pulmonary: Respirations nonlabored; equal air entry bilaterally,
no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable dorsalis pedis pulses
Skin: No rashes or lesions
___ Stroke Scale: Total [2]
1a. Level of Consciousness:
1b. LOC Questions:
1c. LOC Commands:
2. Best Gaze:
3. Visual Fields:
4. Facial Palsy: 1
5a. Motor arm, ___:
5b. Motor arm, right:
6a. Motor leg, ___:
6b. Motor leg, right:
7. Limb Ataxia:
8. Sensory:1
9. Language:
10. Dysarthria:
11. Extinction and Neglect:
Neurologic Examination:
- Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Concentration maintained when recalling months
backwards. Language fluent without dysarthria and with intact
repetition and verbal comprehension. No paraphasic errors.
Follows two-step commands, midline and appendicular. High- and
low-frequency naming intact. Normal reading and writing. Normal
prosody. Registration ___ and recall ___. No apraxia or
neglect. Normal performance on Luria hand sequencing.
- Cranial Nerves: [II] PERRL. VF full to number counting.
Nondilated fundoscopy shows crisp disc margins, no papilledema.
[III, IV, VI] EOM intact, only physiologic end-gaze nystagmus.
[V] V2-V3 with decrease to pinprick on right, not V1. Pterygoids
contract normally. [VII] Minimal right nasolabial fold
flattening. [VIII] Hearing intact to conversation. [IX, X]
Palate elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally. [XII] Tongue midline and moves facilely.
- Motor: Normal bulk and tone. No pronation or drift. No tremor
or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Extensor Digitorum Brevis [R 5] [L 5]
- Sensory: No deficits to light touch, pinprick, or
proprioception bilaterally except decreased sensation to
pinprick on R arm.
- Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 3 2
R ___ 3 2
Plantar response flexor bilaterally.
- Coordination: No dysmetria on finger-to-nose and
heel-knee-shin testing. No dysdiadochokinesia
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable stance without sway. No Romberg. Intact heel,
toe, and tandem gait.
DISCHARGE EXAM: unchanged
Pertinent Results:
___ 10:00PM URINE HOURS-RANDOM
___ 10:00PM URINE HOURS-RANDOM
___ 08:55PM GLUCOSE-107* NA+-140 K+-4.0 CL--102 TCO2-26
___ 08:54PM CREAT-0.8
___ 08:54PM D-DIMER-560*
___ 08:54PM cTropnT-<0.01
___ 08:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:54PM WBC-6.1 RBC-4.11* HGB-12.4 HCT-36.5 MCV-89
MCH-30.1 MCHC-33.9 RDW-14.1
___ 08:54PM NEUTS-55.9 ___ MONOS-2.9 EOS-4.8*
BASOS-0.7
___ 08:54PM ___ PTT-30.6 ___
___ 08:30AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0 Cholest-205*
___ 08:30AM BLOOD Triglyc-77 HDL-56 CHOL/HD-3.7
LDLcalc-134*
NC Head CT:
No intra or extra-axial hemorrhage, mass effect, or shift of
midline
structures is present. Differentiation of the gray and white
matter is
preserved. The sulci, basal cisterns, and ventricles are
normal. Mild
mucosal thickening is demonstrated within the ethmoid air cells,
bilateral maxillary sinuses, and left sphenoid sinus with an
air-fluid level noted in the right sphenoid sinus. The mastoid
air cells and frontal sinuses are clear. There are no osseous
or soft tissue abnormalities otherwise demonstrated.
MRI-
No evidence of acute ischemia
MRA- no evidence of stenosis or calcification of vessels
Medications on Admission:
Medications:
- albuterol inhaler PRN
- fluticasone nasal
- lisinopril 2.5 mg daily
- omeprazole ___ 40 mg daily
- pramipexole 0.125 mg qhs (recently added)
- pravastatin 40 mg qhs
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Fexofenadine 60 mg PO BID
3. Pravastatin 40 mg PO HS
4. Omeprazole 40 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY *Research
Pharmacy Approval Required* Research protocol ___
6. Calcium Carbonate 500 mg PO QID:PRN acid reflux *Research
Pharmacy Approval Required* Research protocol ___
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Fexofenadine 60 mg PO BID
3. Pravastatin 40 mg PO HS
4. Omeprazole 40 mg PO DAILY *Research Pharmacy Approval
Required* Research protocol ___
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY *Research
Pharmacy Approval Required* Research protocol ___
6. Calcium Carbonate 500 mg PO QID:PRN acid reflux *Research
Pharmacy Approval Required* Research protocol ___
Discharge Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Right hand weakness, now resolved.
TECHNIQUE: Contiguous MDCT acquired axial images were obtained through the
brain without intravenous contrast administration. Coronal and sagittal
reconstructions were performed.
COMPARISON: CT head ___. MRI head ___.
FINDINGS:
No intra or extra-axial hemorrhage, mass effect, or shift of midline
structures is present. Differentiation of the gray and white matter is
preserved. The sulci, basal cisterns, and ventricles are normal. Mild
mucosal thickening is demonstrated within the ethmoid air cells, bilateral
maxillary sinuses, and left sphenoid sinus with an air-fluid level noted in
the right sphenoid sinus. The mastoid air cells and frontal sinuses are
clear. There are no osseous or soft tissue abnormalities otherwise
demonstrated.
IMPRESSION:
No acute intracranial abnormality. MRI is more sensitive for the detection of
acute ischemia.
Pansinus disease, with air-fluid level in the right sphenoid sinus suggestive
of acute inflammation.
Radiology Report
HISTORY: Chest pain. Evaluate for pulmonary embolus.
TECHNIQUE: MDCT axial images were acquired from the thoracic inlet to the
dome of the liver after the uneventful administration of 100 mL of Omnipaque.
Coronal and sagittal reformations are provided and reviewed. Max intensity
projection images were created and reviewed as well.
COMPARISON: None.
FINDINGS:
Contrast is seen opacifying the segmental and subsegmental vessels of the
pulmonary arterial tree, without a filling defect to suggest a pulmonary
embolus. The aorta and main pulmonary artery are normal in caliber. There is
no dissection or acute aortic injury. The heart is normal in size and there
is no pericardial effusion.
The image thyroid is normal. There is no axillary, hilar or mediastinal
lymphadenopathy. The esophagus is unremarkable.
The trachea is normal in caliber. The airways are patent to the subsegmental
level. There is no pleural effusion pneumothorax. There is no focal airspace
consolidation. The pleural surfaces are smooth.
This study was not designed to evaluate the subdiaphragmatic contents. Images
of the arterially enhanced liver and spleen are unremarkable.
There is a moderate dextroscoliosis of the thoracic spine. Bilateral
prepectoral breast implants are noted.
IMPRESSION:
No pulmonary embolus.
Radiology Report
CTA OF THE HEAD AND NECK, ___
HISTORY: ___ female with possible stroke; evaluate for stenosis or
dissection.
TECHNIQUE: Routine ___ enhanced CTA of the head and neck, comprising
helical 1.25-mm axial MDCT sections from the level of the main pulmonary
artery through the cranial vertex during dynamic intravenous administration of
70 mL Omnipaque-350. Multiplanar thick-slab MIP-reconstructed and rotational
volume-rendered 3D-reconstructed and curved planar reformatted images were
prepared and viewed on a separate workstation.
FINDINGS: The study is compared with the cranial NECT obtained approximately
one hour earlier, as well as the enhanced MR examination, obtained roughly 11
hours later.
There is a normal appearance of the aortic arch and great vessel origins,
without significant calcified or soft plaque. There is a similarly
unremarkable appearance to the common and cervical internal and external
carotid arteries, with no significant mural irregularity or flow-limiting
stenosis. The proximal and distal ICA minimum diameter (D min) measurements
are as follows: On the right, 8 mm and 4 mm and on the left, 6.0 mm and 4 mm,
with no flow-limiting or tandem stenosis. There is a slightly dominant left
vertebral artery and both vessels demonstrate normal course, caliber and
contour and uniform enhancement from their subclavian origins through the
vertebrobasilar junction, with no finding to suggest dissection.
The intracranial carotid and proximal middle and anterior cerebral arteries
are normal with no significant mural irregularity or flow-limiting stenosis.
The basilar artery demonstrates normal caliber and contour, with no
significant mural irregularity or flow-limiting stenosis. There is a
"patulous" basilar summit with conjoined origins of its terminal vessels.
There is, including a prominent infundibular origin of the left superior
cerebellar artery and the diminutive P1 segment of that posterior cerebral
artery, with a fetal-equivalent left PCA. Robust anterior and right posterior
communicating vessels are demonstrated, with no aneurysm larger than 2 mm.
There is prompt, symmetric opacification of the principal dural venous sinuses
and major deep cerebral veins, with no finding to suggest thrombosis.
The limited included lung apices are clear, that portion of the superior
mediastinum is grossly unremarkable. The thyroid gland is grossly symmetric
and unremarkable, and there is no cervical lymphadenopathy. The included
aerodigestive tract is grossly unremarkable, with no exophytic mucosal lesion.
There is mucosal thickening involving the maxillary antra, with mucus
retention cyst on the left, the anterior and posterior ethmoidal and the
sphenoid air cells, with likely small amount of layering fluid in the
hypoplastic right sphenoid air cell, which may indicate an acute inflammatory
component. Noted is reversal of the normal cervical lordosis with severe
multilevel degenerative disease and significant spinal canal and neural
foraminal narrowing, most marked at the C5-6 and C6-7 levels.
IMPRESSION:
1. Unremarkable cranial and cervical vessels with no evidence of
steno-occlusive disease or dissection.
2. No finding to suggest cerebral venous thrombosis.
3. Chronic inflammatory disease in the paranasal sinuses, with possible acute
inflammatory component involving the right sphenoid air cells; correlate
clinically.
4. Severe cervical spondylosis with significant ventral canal and bilateral
neural foraminal stenosis, particularly at the C4-5 through C6-7 levels,
incompletely evaluated.
COMMENT: A preliminary interpretation to this effect was placed on RISweb by
Dr. ___ (9:04 p.m., ___.
Radiology Report
BRAIN MRI WITH AND WITHOUT CONTRAST, ___
INDICATION: ___ woman with history of breast cancer, now with one day
of right face and arm numbness. Evaluate for cerebrovascular accident, other
process.
COMPARISON: ___.
TECHNIQUE: Sagittal T1-weighted, and axial T1-weighted, T2-weighted, FLAIR,
gradient echo, and diffusion-weighted images of the brain were obtained.
Following intravenous gadolinium administration, axial T1-weighted and
sagittal MP-RAGE images of the brain with multiplanar reformations were
obtained.
FINDINGS: There is no evidence for an intra-axial or extra-axial enhancing
lesion to suggest intracranial metastatic disease. There is no acute
infarction, edema, mass effect, or evidence of blood products in the brain
parenchyma. Ventricles, basal cisterns, and cerebral sulci are normal in size
and configuration. Major arterial flow voids are grossly preserved. ___
cisterna magna is again noted, a normal variant.
Endplate osteophytes are again noted in the imaged upper cervical spine at
C3-4 and C4-5, abutting the ventral spinal cord, incompletely evaluated.
There is mild-to-moderate mucosal thickening in bilateral ethmoidal air cells,
and mild mucosal thickening in bilateral maxillary and sphenoid sinuses.
There is also a small mucous retention cyst in the left maxillary sinus.
Right frontal sinus is unremarkable. Left frontal sinus is not pneumatized.
IMPRESSION: No evidence of an acute infarction or other acute intracranial
abnormalities. No evidence of intracranial metastatic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Numbness, Facial numbness
Diagnosed with OTHER MALAISE AND FATIGUE, PAINFUL RESPIRATION, PRIM CARDIOMYOPATHY NEC
temperature: 97.4
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 77.0
level of pain: 7
level of acuity: 1.0 | ___ yo. w/PMH of breast CA dx ___ s/p chemo-radiation, PE while
on chemo, HTN, HL, presents with 1 hour of right face and arm
numbness; initially also with slight right facial droop.
On arrival to ___, stroke code was called with NIHSS of 2, CT
was done with CTA which showed no signs of hemhorrage or
ischemia and no vessel stenosis to explain her symptoms. She
was admitted and placed on tele with no events seen. MRI was
done which showed no ischemia lesion to account for her
symptoms. Her symptoms are consistent with TIA, she has
elevated LDL (134) and we continued with her dose of statins.
However, one should consider switching her statins to
Atorvastatin (___) or increase her current brand of statins.
She has a remote smoking history and breast CA but otherwise no
other obvious risk factors. Homocysteine and fibrinogen levels
were sent as workup for a general assessment of possible
pro-coagulable state. Fibrinogen was normal 307 and
homocysteine is still pending at time of discharge. ___ was
deferred as she had normal study in ___. Was discharged on
ASA and statin ___.
# Neuro:
- Distribute stroke information packet and note in the chart
- CT/CTA- no stroke or stenosis found
- MRI head - no acute ischemia or vessel disease
- Assess stroke risk factors with telemetry, fasting lipid panel
and HbA1c. LDL was elevated, started statin. HbA1c within norm
limits
- Give full-dose aspirin in ED, and continue ASA 81 mg daily
.
# ___:
- Telemetry
- Allow BP to autoregulate with goal SBP < 180 (goal SBP
140-180s)
- Labetalol 200 mg PO Q6H PRN SBP > 180
- Hold home antihypertensives (lisinopril 2.5 mg daily)
- TTE with bubble - deferred due to normal echo ___
.
# ENDO:
- HbA1c - 6.1
- Finger sticks QID
.
PPX:
- DVT: S/C heparin/pneumoboots
- GI: PRN laxatives + continue home-dose PPI
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
7 weeks of nausea/vomiting
Major Surgical or Invasive Procedure:
Upper endoscopy with biopsies and nasojejunal tube placement
___
Right breast core biopsy ___
Chest port placement ___
History of Present Illness:
___ yo F w/ PMH of epilepsy (on lamictal), IDDM, HTN,
hyperlipidemia, chronic venous insufficiency who presents with
nausea & vomiting x 7 weeks.
Patient reports inability to tolerate food or water for the past
7 weeks - if she tries to eat some food, she will have emesis.
Also with cough over the past several weeks. Last BM was the day
before yesterday. Denies fevers. Reports glucose of 83 this AM
(on 70/30 insulin). Has been to the ER three times for similar
presentations. Had appointment on ___ at ___ -
endoscopy yesterday with biopsies - awaiting results. Denies
respiratory distress, chest pain, SOB. States she has not eaten
in 7 weeks. endorses nausea at this time and is spitting up
froth. Denies chest pain, dyspnea, fever, chills.
In the ED, initial vitals were: 97.8 148/89 76 18 100%RA
- Exam notable for:
VSS
Well, overweight
RRR, no murmurs
CTAB
Soft, NTND
Neuro non-focal
- Labs notable for:
platelets ___
---------<140
2.9/28/0.6
normal LFTs
negative troponin
- Imaging was notable for:
CXR PA/LAT
AP upright and lateral views of the chest provided. Patient is
slightly rotated to the left.
Lung volumes are low. There is mild bibasilar atelectasis. No
large effusion or pneumothorax. The heart appears mildly
enlarged. Mediastinal contour is normal. Bony structures are
intact. AC joint arthropathy noted bilaterally. No free air
below the right hemidiaphragm.
CT abd/pelvis with contrast read pending
- Patient was given: 1L NS, 4mg ondansetron, 40mEq KCL IV
started
- Vitals prior to transfer: 162/64 78 18 98%RA
Upon arrival to the floor, patient reports recounts the above.
She has been feeling weak, spitting up white frothy phlegm, felt
dizzy, and is afraid to fall. She has developed dyspnea with
exertion up stairs.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Hypertension, essential, benign
Hypercholesterolemia
DM (diabetes mellitus), type 2, uncontrolled
s/p right fem/pop bypass graft ___
Seizure disorder
Colonic adenoma
Obesity
Social History:
___
Family History:
no FH of colon cancer or stomach cancer or liquid tumors
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.2 164/74 87 18 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae 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, mild epigastric tenderness, mildly distended,
bowel sounds present, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNIII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 98.6, 115-125/60s, 80s, 16, 96% RA
General: Uncomfortable, a&ox3
HEENT: Sclerae anicteric, MMM, EOMI, NJT in right nares,
bridled.
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, distended mild epigastric tenderness, no rebound
or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, bilateral
venous stasis changes
Neuro: Grossly normal.
Pertinent Results:
ADMISSION LABS
==============
___ 04:38PM BLOOD WBC-6.4 RBC-4.60 Hgb-12.8 Hct-39.1 MCV-85
MCH-27.8 MCHC-32.7 RDW-14.9 RDWSD-46.4* Plt ___
___ 04:38PM BLOOD Neuts-63.8 Lymphs-16.5* Monos-19.5*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.10 AbsLymp-1.06*
AbsMono-1.25* AbsEos-0.00* AbsBaso-0.00*
___ 04:38PM BLOOD Glucose-140* UreaN-7 Creat-0.6 Na-146*
K-2.9* Cl-103 HCO3-28 AnGap-18
___ 04:38PM BLOOD ALT-9 AST-13 LD(LDH)-239 AlkPhos-63
TotBili-0.4
___ 04:38PM BLOOD Lipase-12
___ 04:38PM BLOOD cTropnT-<0.01
___ 04:38PM BLOOD Albumin-3.5 Calcium-8.8 UricAcd-4.1
PERTINENT LABS
==============
___ 06:40AM BLOOD CEA-25.6* CA125-417*
___ 07:40AM BLOOD PEP-TWO TRACE IgG-961 IgA-259 IgM-50
IFE-TRACE MONO
___ 13:47 BLOOD CA ___ ___
IMAGING
=======
CT ABDOMEN & PELVIS WITH CONTRAST ___:
IMPRESSION:
1. Retroperitoneal soft tissue lesion detailed above with
scattered areas of omental nodularity and small volume ascites.
Findings concerning for
peritoneal carcinomatosis, possibly in the setting of a GI
primary malignancy, please correlate with recent endoscopy
results.
2. Probable cystitis with ureteritis. Correlate with UA.
3. Hyperemic thickened stomach, may represent gastritis,
possibly related to recent endoscopy.
4. Small pleural effusions, left greater than right lower lobe
compressive
atelectasis.
CT CHEST WITH CONTRAST ___:
IMPRESSION:
1. No worrisome pulmonary nodules.
2. Multifocal lucencies within several ribs, of uncertain
significance, but might be seen in setting of myeloma.
3. Right sided irregular breast nodule as described. Correlate
with prior
breast imaging or consider dedicated imaging if clinically
indicated and
recent breast imaging has not been performed.
4. Left adrenal/retroperitoneal nodularity/soft tissue
thickening as
described on the CT of the abdomen pelvis from 2 days ago.
MR HEAD W/ AND W/O CONTRAST ___:
IMPRESSION:
1. No evidence of enhancing mass or abnormal enhancement to
suggest metastatic disease.
2. No evidence of infarction, hemorrhage or edema.
3. Mild diffuse parenchymal volume loss.
RLE LENIS ___:
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Limited evaluation the right posterior tibial and peroneal
veins.
BONE SCAN ___:
FINDINGS: The images show no abnormal radiotracer uptake in the
axial or
appendicular skeleton.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION: No evidence of osseous metastases.
RIGHT BREAST US ___:
IMPRESSION:
Right breast mass is suspicious. Ultrasound-guided core biopsy
is
recommended.
RECOMMENDATION: Ultrasound-guided core biopsy of right breast
mass.
NOTIFICATION: Findings and recommendations were communicated to
the patient at the time of imaging. Ultrasound-guided core
biopsy already was planned for immediately following imaging per
prior discussion with referring clinicians.
BI-RADS: 4B Suspicious - moderate suspicion for malignancy.
CHEST CT WITHOUT CONTRAST ___
Metallic marker in the right chest wall appears to be in
relation to the
inferior aspect of the previously noted right inferolateral
breast nodule
Bilateral pleural effusion, slightly increased
PORT PLACEMENT ___
Successful placement of a double lumen chest power Port-a-cath
via the left internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
PERTINENT STUDIES
=================
BREAST CORE BIOPSY ___:
PATHOLOGIC DIAGNOSIS:
Right breast, core needle biopsy:
- Dense fibrous stroma. See note.
Note: Breast parenchyma is not identified in this limited
sample. MNF116 and p63 immunostains support the diagnosis as
above.
EGD ___:
Impression:
-Normal mucosa in the whole esophagus
-Erythematous, nodular and friable mucosa was noted in the whole
stomach. -The gastric folds were thickened and the walls failed
to distend on insufflation. These endoscopic findings are
suggestive of malignant infiltration of the stomach in the form
of Linitis Plastica. Cold forceps biopsies were performed for
histology.
-No tight strictures amenable to stent placement were found.
-Normal mucosa in the whole duodenum
-A NJT was successfully placed under endoscopic and fluoroscopic
guidance.
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-3.9* RBC-3.17* Hgb-8.7* Hct-27.4*
MCV-86 MCH-27.4 MCHC-31.8* RDW-15.9* RDWSD-50.3* Plt ___
___ 05:44AM BLOOD Neuts-71.7* Lymphs-9.8* Monos-17.0*
Eos-0.6* Baso-0.1 Im ___ AbsNeut-7.72* AbsLymp-1.06*
AbsMono-1.83* AbsEos-0.07 AbsBaso-0.01
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-235* UreaN-22* Creat-0.7 Na-135
K-4.0 Cl-102 HCO3-23 AnGap-14
___ 06:10AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. 70/30 23 Units Breakfast
70/30 23 Units Dinner
3. Benzonatate 100 mg PO TID
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. LamoTRIgine 100 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO DAILY
10. Pravastatin 20 mg PO QPM
11. Pantoprazole 40 mg PO Q24H
12. Metoclopramide 5 mg PO QIDACHS
Discharge Medications:
1. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
2. Glycopyrrolate 1 mg PO BID
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. LORazepam 1 mg PO Q8H:PRN nausea
RX *lorazepam 1 mg 1 tab by mouth every eight (8) hours Disp
#*21 Tablet Refills:*0
5. Ondansetron ODT 8 mg PO Q8H:PRN nausea
6. Prochlorperazine 25 mg PR Q12H:PRN nausea
7. Glargine 20 Units Bedtime<br> 70/30 56 Units Q24H
Insulin SC Sliding Scale using HUM Insulin
8. Clopidogrel 75 mg PO DAILY
9. LamoTRIgine 100 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Pravastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Gastric adenocarcinoma
- Diarrhea
- Nausea
- Diabetes mellitus type 2
- Hypertension
- Seizure disorder
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 (AP AND LAT)
INDICATION: ___ with HTN, HL, diabetes who presents with nausea spitting
up phlegm x 7 weeks// Rule-out PNA
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. Patient is slightly
rotated to the left.
Lung volumes are low. There is mild bibasilar atelectasis. No large effusion
or pneumothorax. The heart appears mildly enlarged. Mediastinal contour is
normal. Bony structures are intact. AC joint arthropathy noted bilaterally.
No free air below the right hemidiaphragm.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with HTN, hyperlipidemia who presents with nausea and
vomiting x 7 weeks, endoscopy yesterday
TECHNIQUE: Multidetector CT through the abdomen pelvis performed following
administration of IV contrast. No oral contrast administered. Multiplanar
reformations provided.
DOSE: Total DLP (Body) = 821 mGy-cm.
COMPARISON: Prior exam from ___.
FINDINGS:
LOWER CHEST: There is trace right and small left pleural effusion with
compressive atelectasis left greater than right. Heart is normal in size and
shape. Mild aortic valvular calcifications noted.
ABDOMEN: The liver enhances normally without focal concerning lesion. There
is small volume perihepatic ascites. No biliary ductal dilation. The main
portal vein and central branches appear patent. The gallbladder is
decompressed and appears normal. The pancreas enhances normally. No signs of
pancreatitis or ductal dilation. Spleen is normal in size. Right adrenal
gland appears normal. Kidneys enhance symmetrically and demonstrate prompt
excretion of contrast. No hydronephrosis or signs of pyelonephritis. There
is mild thickening of the mid and distal ureters which could reflect an
ascending infection. Please correlate clinically.
The stomach appears diffusely thickened and hyperemic. Abnormal
retroperitoneal soft tissue density is seen inferior to and abutting the GE
junction, series 601b 33 with loss of fat plane with the adjacent stomach.
This soft tissue lesion measures approximately 4.7 x 5.0 x 1.9 cm and is
concerning for malignancy. Differential considerations include lymphoma or
metastatic disease in the setting of a GI tract malignancy. Soft tissue
density extends along the proximal abdominal aorta and appears to encase the
left renal artery. This soft tissue lesion is inseparable from the left
adrenal gland which is not definitively visualized. Irregular soft tissue
density is noted in the left upper abdomen adjacent to the greater curvature
of the stomach on series 2, image 22 concerning for omental tumor implant.
Additional sites of omental nodularity can be seen in the upper abdomen on
series 2, image 27 and on series 2 image 29. A lymph node is noted on series
2, image 49 along the lower retroperitoneal chain measuring 8 mm in short
axis. There is a small volume of ascites.
The duodenum appears unremarkable. Small bowel loops demonstrate no signs of
ileus or obstruction. The appendix is not visualized though no secondary
signs of appendicitis seen. The colon is mostly decompressed and contains
only a mild fecal load. No free air seen.
PELVIS: The urinary bladder is decompressed though the wall appears somewhat
hyperemic and thickened, correlate for cystitis. Uterus is surgically absent.
No adnexal mass is seen. No pelvic sidewall or inguinal adenopathy. Small
volume free fluid tracks into the pelvis.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Retroperitoneal soft tissue lesion detailed above with scattered areas of
omental nodularity and small volume ascites. Findings concerning for
peritoneal carcinomatosis, possibly in the setting of a GI primary malignancy,
please correlate with recent endoscopy results.
2. Probable cystitis with ureteritis. Correlate with UA.
3. Hyperemic thickened stomach, may represent gastritis, possibly related to
recent endoscopy.
4. Small pleural effusions, left greater than right lower lobe compressive
atelectasis.
RECOMMENDATION(S): Please correlate with results of endoscopy from outside
hospital performed yesterday.
Urinalysis to assess for infection.
NOTIFICATION: Findings were discussed with Dr ___.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ patient with soft tissue mass in the abdomen,
concerning for gastric cancer. Evaluate for metastasis.
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: MRI head ___
FINDINGS:
There is no evidence of enhancing mass or abnormal enhancement to suggest
metastasis. There is no infarction, haemorrhage, or edema. There is mild
diffuse parenchymal volume loss. There is mild mucosal thickening of
bilateral ethmoid air cells with partial opacification of bilateral mastoid
air cells. Patient is status post bilateral lens replacement. The dural
venous sinuses appear patent.
IMPRESSION:
1. No evidence of enhancing mass or abnormal enhancement to suggest metastatic
disease.
2. No evidence of infarction, hemorrhage or edema.
3. Mild diffuse parenchymal volume loss.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with progressive nausea/vomiting x6 weeks found
to have retroperitoneal mass and potential gastric cancer// Please evaluate
for any evidence of metastasis, lymphadenopathy, staging
TECHNIQUE: CT of the chest was performed after administration of IV contrast.
Omnipaque 350 was given for this examination.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 32.8 cm; CTDIvol = 14.6 mGy (Body) DLP = 477.7
mGy-cm.
Total DLP (Body) = 478 mGy-cm.
COMPARISON: No comparison study.
FINDINGS:
Visualized aspect of the thyroid gland is homogeneous. There is no axillary,
mediastinal, or hilar lymphadenopathy by size criteria. There is a common
origin of the innominate artery and the left common carotid ( "bovine arch",
normal variant). Heart and pericardium are grossly unremarkable.
Small bilateral pleural effusions are seen. Mild associated bibasilar
atelectasis is seen at both bases.
There is no concerning pulmonary nodule or mass. Coarse calcifications seen
at the anterior aspect of the left costophrenic angle in the inferior aspect
of the lingula (series 601, image 51) likely related to prior infection, or
possibly aspiration of prior oral barium administration.
Incidental note made of a lipoma within the level left subscapularis muscle.
Limited visualized of the upper abdomen demonstrates a small amount of ascites
fluid. Partially visualized is a left adrenal or retroperitoneal
nodularity/thickening which measures up to 15 x 22 mm (series 2, image 46).
Small retroperitoneal lymph nodes are also notable.
Irregularly marginated and probably enhancing right lower lateral deep breast
nodule (series 2, image 31) noted, measuring 14 x 17 mm.
Tiny focal regions of cortical lucencies are seen in the left second, third,
and fourth ribs (series 4, images 108, 61, 51). These are nonspecific, but
processes such as myeloma or metastases are in imaging consideration; consider
bone scan for further assessment
IMPRESSION:
1. No worrisome pulmonary nodules.
2. Multifocal lucencies within several ribs, of uncertain significance, but
might be seen in setting of myeloma.
3. Right sided irregular breast nodule as described. Correlate with prior
breast imaging or consider dedicated imaging if clinically indicated and
recent breast imaging has not been performed.
4. Left adrenal/retroperitoneal nodularity/soft tissue thickening as
described on the CT of the abdomen pelvis from 2 days ago.
RECOMMENDATION(S): Dedicated breast imaging and bone scan as clinically
indicated.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old woman with likely gastric cancer and asymmetric lower
extremity edema R>L. Assess for deep venous thrombosis.
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. Limited evaluation of the right
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 right lower extremity veins.
Limited evaluation the right posterior tibial and peroneal veins.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND
INDICATION: ___ woman with suspicious mass on chest CT ___
for further diagnostic evaluation. Recent gastrointestinal mucosal biopsy due
to concern for stomach malignancy.
COMPARISON: Chest CT ___, mammogram ___ and ___
TECHNIQUE: Targeted right breast ultrasound was performed.
FINDINGS:
Targeted ultrasound of the right breast was performed in the location of right
breast mass seen on recent CT in the lower outer right breast. At the 8
o'clock position of the right breast 15 cm from the nipple, there is a
hypoechoic mass with irregular margins measuring at least 10 x 7 x 4 mm.
There is no additional suspicious solid or cystic mass.
IMPRESSION:
Right breast mass is suspicious. Ultrasound-guided core biopsy is
recommended.
RECOMMENDATION: Ultrasound-guided core biopsy of right breast mass.
NOTIFICATION: Findings and recommendations were communicated to the patient
at the time of imaging. Ultrasound-guided core biopsy already was planned for
immediately following imaging per prior discussion with referring clinicians.
BI-RADS: 4B Suspicious - moderate suspicion for
malignancy.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND GUIDED CORE BIOPSY WITH CLIP PLACEMENT
INDICATION: ___ woman for ultrasound-guided core biopsy of suspicious
right breast mass.
COMPARISON: The relevant current/recent imaging was available for this
procedure.
FINDINGS:
At the 8 o'clock position of the right breast 15 cm from the nipple, there is
hypoechoic mass measuring at least 7 mm in greatest diameter, as seen on
diagnostic ultrasound performed immediately prior to the time of the biopsy.
This was targeted for ultrasound-guided core biopsy.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers.
Allergies and/or Medications: Reviewed prior to the procedure.
Clinicians: ___, MD.
Description: Using ultrasound guidance, aseptic technique and 1% lidocaine for
local anesthesia, a 13-gauge coaxial needle was placed adjacent to the lesion
and using a 14-gauge Bard spring-loaded biopsy device, 5 cores were obtained.
Next, a percutaneous HydroMark coil was deployed under ultrasound guidance.
The needle was removed and hemostasis was achieved.
Estimated blood loss: < 1 cc.
Specimens: Sent to pathology.
Anesthesia: ___ cc 1% lidocaine
Complications: No immediate complications.
Post procedure diagnosis: Same.
Postprocedure mammogram was deferred due to health status as inpatient.
IMPRESSION:
Technically successful US-guided core biopsy of the right breast lesion.
Pathology is pending.
The patient expects to hear the pathology results from her referring provider
___ ___ business days. Standard post care instructions were provided to the
patient.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with prior identified right breast nodule s/p
US guided biopsy with benign findings// Please perform limited CT of the chest
and see if the biopsy marking clip corresponds prior breast nodule found on CT
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
The metallic marker appears to be in relation to the inferior aspect of the
previously noted right inferolateral breast nodule (5, 150).
Aorta and pulmonary arteries are normal in diameter. Multiple small
mediastinal lymph nodes are not pathologic heart size is normal. There is no
pericardial effusions there is bilateral moderate pleural effusion that
appears to be minimally increased since the prior study on the right and
unchanged on the left. Bibasal atelectasis related to the presence of pleural
effusion is unchanged
NG tube tip is in the stomach
Lingular calcification is unchanged. No additional nodules masses or
consolidations demonstrated.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
IMPRESSION:
Metallic marker in the right chest wall appears to be in relation to the
inferior aspect of the previously noted right inferolateral breast nodule
Bilateral pleural effusion, slightly increased
Radiology Report
INDICATION: ___ year old woman with gastric cancer, plan to start chemotherapy
with FOLFOX as inpatient requires port for access per this protocol// Please
place double lumen left-side port. leave accessed to start inpatient chemo.
Patient is on clopidogrel. Reviewed with ___.
COMPARISON: Chest CT ___.
TECHNIQUE: OPERATORS: Dr. ___ resident 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
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 31 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: None ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.6 min, 6 mGy
PROCEDURE
1. Left internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The double lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
ethilon sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the left
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with gastric adenocarcinoma with excessive
salivation and concern for aspiration complains of shortness of breath// to
assess for aspiration pneumonia
IMPRESSION:
In comparison with the scout there is hazy opacification involving both lungs,
more prominent on the right, consistent with layering pleural effusions and
underlying compressive atelectasis. Cardiac silhouette is enlarged and there
is mild engorgement of the pulmonary vessels consistent with elevated
pulmonary venous pressure. Given these extensive changes, it would be
impossible to exclude superimposed aspiration/pneumonia in the appropriate
clinical setting, especially in the absence of a lateral view.
Dobhoff tube extends at least to the lower body of the stomach were crosses
the inferior margin of the image. Left IJ Port-A-Cath extends to the junction
of the brachiocephalic vein and superior vena cava.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.8
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ with epilepsy, hypertension,
diabetes on insulin who presented with 7 weeks of poor PO intake
found to have soft tissue abdominal mass on CT concerning for GI
malignancy and then subsequently found to have intestinal type
gastric adenocarcinoma on biopsy results from ___ EGD and
___ EGD with metastatic disease in retroperitoneum. Also s/p
breast biopsy which was benign. NJT was placed and will likely
be definitive nutrition source for now as she was unable to
tolerate any POs due to linitis plastica of the stomach. She was
given cycled tube feeds and insulin was adjusted accordingly.
When path results were finalized, she had a port placed and she
was transferred to OMED for initiation of FOLFOX chemotherapy
ACTIVE ISSUES:
# Intestinal type gastric adenocarcinoma: Biopsy results from
___ EGD and ___ EGD with intestinal type gastric
adenocarcinoma with metastatic disease to retroperitoneum. EGD
also with linitis plastica. Staging scans were completed. Bone
scan did not show evidence of osseous mets though CT had some
scattered lucent lesions so SPEP and UPEP were performed to look
for evidence of myeloma. Dr. ___ will be primary
oncologist. Further staining will be performed to see if may be
responsive to trastuzumab or pembrolizumab. She was started on
FOLFOX (C1D1 ___, which she tolerated well. She will
follow-up with Atrius Oncology on discharge
# Nausea/vomiting/fatigue
# Severe malnutrition: Likely due to malignant gastric
infiltration. She was strict NPO due to probable obstruction at
GE junction. She received cycled tube feeds via dobhoff with
nepro (75ml/hr x 12 hrs/day). Two surgical attendings declined
to place J-tube due to high risk of complications with her
disease burden in the upper abdomen. ___ will be the
definitive management for now unless chemo is able to improve
her ability to swallow and tolerate PO or if it reduces her
disease burden to the point that it becomes safe to place a J
tube. Started Zofran, Ativan, and Compazine for symptomatic
control of nausea. Started glycopyrrolate and scopolamine patch
for symptomatic control of increased oral secretions.
#Diarrhea: Began having increased liquid stool output. Cdiff was
negative. Her diarrhea may be secondary to chemotherapy or her
cancer. She was started on loperamide and lomotil for
symptomatic control
#Hypertension: Continued home losartan
#Seizure d/o: Continued home lamotrigine
#DM2: ___ consulted for assistance with management given tube
feeds. See below in transitional issues for insulin regimen.
#PAD: S/p right fem/pop bypass graft ___. On aspirin and Plavix
at home but no clear indication for DAPT so aspirin was
discontinued. Plavix held prior to port placement and it was
restarted afterward.
TRANSITIONAL ISSUES
===================
# STOPPED Metoprolol tartrate as unclear indication
# STARTED Tube feeds (listed below under "Discharge Diet")
# STARTED Zofran, Ativan, and Compazine for nausea
# STARTED glycopyrrolate for increased oral secretions. Can also
try scopolamine patch if secretions worsen
# Consider outpatient J-tube placement if she has good response
to chemotherapy
# Per ___ recs, her insulin regimen should be:
-- 70/30 56U at time of initiation of tube feeds
-- Lanus 20U at bedtime
-- Humalog sliding scale:
6a 12n 6p 10p
150-200 3 1 3 3
___ 12
___ 15
# Per ___ recs, if patient is given dexamethasone with chemo,
adjustments to insulin will need to be made as follows:
- If dex given in the AM, increase dose of 70/30 by 5 units
- If dex given in the ___, increase dose of 70/30 by 10 units and
change corrective insulin scale to 150:3,200:6,250:9, etc.
# CONTACT: Husband. alternate is ___, her son,
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache/head collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male was playing rugby when he had a witnessed head
to head collision with another player. Patient recalls catching
a ball and then nothing until EMS workers were attending to him.
According to witnesses, following his loss of conciousness, Mr.
___ had a generalized tonic clonic seizure lasting one to two
minutes. EMS arrived and transported the patient to ___ with
a
GCS of 15. Patient denies any nausea, vomiting or visual
changes.
He does endorse a slight headache.
Past Medical History:
Pt reports 2 concussions, one during freshman year in high
school
and one during ___ year of college.
Social History:
___
Family History:
NC
Physical Exam:
O: T:97.4 BP:153/50 HR:70 R18 100RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on discharge:
A&Ox3
PERRL, face symmetrical
No drift
MAE ___
Senstaion intact to light touch
Pertinent Results:
___: Non contrast head CT
IMPRESSION:
Small right frontoparietal subdural hemorrhage at the vertex
___: Non contrast head CT
IMPRESSION:
Interval decrease and redistribution of right subdural hematoma
along the cerebellar tentorium. No new areas of hemorrhage or
infarction.
Medications on Admission:
MVI
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN HA
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth Q 6hrs Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth Q 4hrs Disp #*40 Tablet
Refills:*0
4. Senna 1 TAB PO HS
5. LeVETiracetam 500 mg PO BID
Please take this medication util you are instructed to stop at
your follow up appointment.
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic head injury with right frontal SDH.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ man with frontoparietal subdural hematoma approximately
6 mm in width. Evaluate interval change in bleed.
TECHNIQUE: Contiguous axial MDCT images of the brain were acquired without
the administration of IV contrast. Reformatted coronal and sagittal and thin
section bone algorithm reconstructed images were obtained.
COMPARISON: Nonenhanced CT scan of the head from ___.
FINDINGS:
There has been interval decrease and re-distribution of the subdural hematoma
along the cerebellar tentorium (601b:85). There is no evidence of mass effect
or shift of midline structures. There are no new areas of hemorrhage or
infarction. Basal cisterns appear patent, and there is preservation of
gray-white matter differentiation. The bony structures are unremarkable, and
the paranasal sinuses are well aerated. The mastoid air cells and middle ear
cavities are clear. The globes unremarkable.
IMPRESSION:
Interval decrease and redistribution of right subdural hematoma . No new
areas of hemorrhage or infarction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P RUGBY TACKLE
Diagnosed with SUBDURAL HEM-BRIEF COMA, IN SPORTS WITH FALL, ACTIVITIES INVOLVING RUGBY
temperature: 97.4
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 153.0
dbp: 50.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ was admitted to the neurosurgical floor on ___
after a head collision while playing Rugby with + LOC and a ___
min seizure. On presentation he was neurologically intact. He
was kept over night for observations. On ___, he remained
neurologically and hemodynamically stable. A repeat head CT was
obtained and showed redistribution of his right frontalparietal
SDH, along the cerebellar tentorium. Neurology was consulted for
his episode of a tonic clonic seizure post collision. Neurology
recommended to continue with Keppra bid until patient follows up
with them at out patient clinic. Occupational therapy was
consulted and cleared patient to be discharge home. The patient
was discharged home in stable conditions. |
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:
EGD
History of Present Illness:
Mr. ___ is an ___ with recent history of pancreatic
adenocarcinoma with known mesenteric and liver metastases,
chronic right pleural effusion, recent mini laparotomy with
loop transverse colostomy on ___ for colonic obstruction,
and recent admission for constipation who presents with
worsening shortness of breath.
Patient notes acute worsening shortness of breath began
yesterday. Patient living at extended care facility where
became worse today and was unresponsive to nebs. Patient
reports his shortness of breath is worse when eating food.
Also, notes that he feels short of breath when laying flat.
Reports shortness of breath at baseline that has not
significantly improved with nebs recently. He also has a
non-productive cough at baseline secondary to post-nasal drip
that has not changed recently.
Patient denies eating salty foods, including hot dogs, fries,
and canned soup. Patient reports decreased appetite and poor PO
intake. Notes loss of weight over past several weeks.
In the ED, vs were: Temp 98.7 HR 120 BP 103/58 RR 28 O2sat 96%
6L. EKG showed sinus tach @ 115, no ischemic chgs, ? of
alternans. Bedside ultrasound was done that showed no
pericardial effusion. Exam significant for wheezing and
difficulty speaking, patient DNI and placed on BiPAP and became
more comfortable. CXR concering for RLL pneumonia. Labs
notable for Hct 31, plts 480s, Na 130, lactate 1.8. VBG pH
7.40, pCO2 38, pO2 107. Given 125mg methylpred, cefepime,
azithro, and duonebs x3. 2L NS and 2mg Mg IV. On transfer, vs
were: Temp 97.4 HR 70 BP 169/69 RR ___ O2sat 98% on 40%.
On arrival to the MICU, vs were: Temp 98.5 HR 117 BP 109/82 RR
22 O2 sat 88% RA.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough. Denies chest pain, chest pressure, palpitations.
Denies nausea, vomiting, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Asthma (remote hospitalization, otherwise controlled on
inhalers)
2. GERD
3. Pernicious Anemia/B12 Deficiency
4. Depression
5. Osteoarthritis, s/p arthroscopic repair of left knee
6. Gout (2 lifetime episodes, not on meds chronically)
7. PMR
8. BPH
9. History of cardiac tamponade in the setting of pericarditis
10. Metastatic pancreatic cancer to liver and mesenteric
11. Surgical history - Appendectomy, L parotid mass excision,
Tonsillectomy, Diverting loop transverse colostomy ___ -
Dr. ___
Social History:
___
Family History:
No family history of pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: Temp 98.5 HR 117 BP 109/82 RR 22 O2 sat 88% RA.
General- Cachetic appearing man, alert, oriented, no acute
distress
HEENT- Sclera anicteric, dry mucous membranes, poor skin turgor,
oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Bibasilar crackles, no wheezes, rales, ronchi
CV- Sinus tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- distended, no tenderness to palpation, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
stoma in LLQ
pink/healthy appearing with +stool and +gas output
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 100/58 102 18 94%RA
GEN: Alert, oriented X3. Cachetic appearing, no acute signs of
distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MMM.
Neck: Supple, no JVD, no thyromegaly.
Lymph nodes: No cervical, supraclavicular or axillary LAD.
CV: RRR, good S1, S2, no murmurs, rubs or gallops.
RESP: mild bibasilar rales
ABD: distended abdomen, firm but not tense, + bowel sounds,
colostomy pink/patent with moderate stool output.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: grossly intact
PSYCH: Appropriate and calm.
Pertinent Results:
LABS
==========================
___ 11:30PM BLOOD WBC-9.7 RBC-3.51* Hgb-9.3* Hct-31.5*
MCV-90 MCH-26.5* MCHC-29.6* RDW-15.6* Plt ___
___ 06:40AM BLOOD WBC-10.2 RBC-3.02* Hgb-7.9* Hct-25.7*
MCV-85 MCH-26.2* MCHC-30.7* RDW-16.2* Plt ___
___ 07:25AM BLOOD WBC-11.4* RBC-3.11* Hgb-8.2* Hct-26.3*
MCV-85 MCH-26.3* MCHC-31.1 RDW-16.2* Plt ___
___ 06:30AM BLOOD WBC-8.3 RBC-3.11* Hgb-7.8* Hct-27.1*
MCV-87 MCH-25.2* MCHC-29.0* RDW-16.3* Plt ___
___ 07:20AM BLOOD WBC-7.5 RBC-3.08* Hgb-7.9* Hct-27.2*
MCV-88 MCH-25.7* MCHC-29.1* RDW-16.1* Plt ___
___ 07:00AM BLOOD WBC-7.1 RBC-3.07* Hgb-8.0* Hct-27.0*
MCV-88 MCH-26.2* MCHC-29.8* RDW-16.5* Plt ___
___ 11:30PM BLOOD Glucose-107* UreaN-16 Creat-1.2 Na-130*
K-4.8 Cl-95* HCO3-20* AnGap-20
___ 07:15AM BLOOD Glucose-116* UreaN-23* Creat-1.2 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
___ 07:15AM BLOOD Glucose-121* UreaN-21* Creat-1.0 Na-137
K-3.7 Cl-101 HCO3-27 AnGap-13
___ 06:30AM BLOOD Glucose-129* UreaN-19 Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-14
___ 06:40AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
___ 07:25AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
___ 12:54AM BLOOD ___ pO2-107* pCO2-38 pH-7.40
calTCO2-24 Base XS-0 Intubat-NOT INTUBA
___ 11:30PM BLOOD Lactate-1.8
IMAGING/STUDIES
==========================
___ CXR
Worsening right lower lobe opacity is highly concerning for
pneumonia or aspiration. Chronic right pleural effusion. Patchy
opacity in the left lower lobe has also increased.
___ CXR
IMPRESSION: AP chest compared to ___:
Heterogeneous opacification at the base of the right lung which
worsened
substantially after ___, has subsequently improved,
still accompanied
by a small pleural effusion. Time course is consistent with
either resolving
pneumonia or atelectasis.
___ CXR
IMPRESSION: PA and lateral chest compared to ___
through ___:
A tortuous but not particularly dilated esophagus retains
contrast agent from
the preceding swallowing examination. The distal esophagus has
a sharp
tapering, and could be occluded either by stricture or mass,
better evaluated
during fluoroscopic observation earlier.
There is no pneumonia. A small right pleural effusion or
pleural thickening
has been present since at least middle of ___. Heart size
is normal.
Irregular opacification of the lungs suggests severe emphysema,
on the right.
video swallow exam ___
FINDINGS: This exam was performed in conjunction with the
speech and swallow
division. Multiple consistencies of barium were administered.
There was no
evidence of aspiration or penetration. The esophagus was
examined, and there
was holdup of barium at the distal esophagus with significant
residual barium
within the esophagus, which eventually passed into the stomach
after a few
minutes. After more barium was administered, hold up was again
seen, which
did not pass into the stomach after several minutes. There were
multiple
tertiary contractions.
IMPRESSION:
1. No evidence of aspiration or penetration. For further
details please refer
to speech and swallow division note in OMR.
2. Hold up of barium within the distal esophagus, cannot rule
out stricture or
extrinsic compression of the distal esophagus. Endoscopy
recommended.
CTA Chest ___
FINDINGS:
CT of the thorax: There are multifocal areas of consolidations
involving the
left upper and lower lobes. Additionally, there is a
consolidation or partial
lung collapse involving the right lower lobe. There is a stable
nonhemorrhagic left pleural effusion. There are prominent
bronchovascular
bundles raising the concern for lymphatic involvement of the
patient's primary
malignancy.
There is significant dilation of the distal esophagus, the
stomach distally is
collapsed.
CTA thorax: There is atherosclerotic disease of the abdominal
aorta. The
aorta is normal in caliber throughout the thorax without
intramural hematoma
or dissection. The pulmonary arteries are opacified to the
segmental level.
There is no filling defect to suggest pulmonary embolism.
Osseous structures:. There are no concerning lytic or sclerotic
bony lesions.
Although this study is not designed for assessment of the
intra-abdominal
structures, multiple liver lesions appear stable.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Significant dilation of the distal esophagus and multifocal
opacities
involving the left upper and left lower lobe as well as a
consolidation or
partial collapse of the right lower lobe, finding suggest
aspiration.
3. Stable nonhemorrhagic left pleural effusion.
4. Multiple hepatic metastases appear stable.
5. Prominence of the bronchovascular bundles within the lungs
raise the
question of lymphatic involvement of the patient's primary
malignancy.
EGD report:
Impression: Esophagus was mildly dilated. Otherwise no evidence
of mucosal abnormalities, lesions or extrinsic compression. GE
junction was wide open and the scope traversed easily.
Bluish discolouration and distortion along greater curvature of
stomach - may represent varices and/or tumour.
Normal mucosa in the duodenum
Based on the wide patency of GE junction, there is no indication
for esophageal stent insertion and/or Botox injection at the GE
junction.
There is likely a motility defect.
MICROBIOLOGY
==========================
___
Blood and urine cultures negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO QHS
2. BuPROPion 200 mg PO DAILY
3. Cetirizine 10 mg oral daily
4. Doxazosin 8 mg PO HS
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. Sertraline 200 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
12. TraZODone 50 mg PO HS
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
14. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN sob/wheezing
15. Polyethylene Glycol 17 g PO DAILY
16. Acetaminophen 1000 mg PO Q8H:PRN pain
17. Calcium Carbonate 500 mg PO QID:PRN heart burn
18. HydrOXYzine 25 mg PO QHS:PRN itching
19. Milk of Magnesia 30 mL PO Q 3 DAYS constipation
20. Ondansetron 4 mg PO Q8H:PRN nausea
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h SOB
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Acetaminophen 1000 mg PO QHS
3. BuPROPion 200 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN heart burn
5. Doxazosin 8 mg PO HS
6. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Montelukast Sodium 10 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4h SOB
14. Sertraline 200 mg PO QHS
15. TraZODone 50 mg PO HS:PRN insomnia
16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
17. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of
breath, wheezing
18. Docusate Sodium 200 mg PO BID
19. Ipratropium Bromide Neb 1 NEB IH Q6H
20. Lorazepam 0.25-0.5 mg PO Q4H:PRN anxiety
21. Morphine SR (MS ___ 15 mg PO Q12H
22. Morphine Sulfate (Oral Soln.) ___ mg PO Q4H:PRN pain
23. Senna 1 TAB PO BID:PRN constipation
24. Simethicone 40-80 mg PO QID:PRN gas or bloating
25. Cetirizine 10 mg oral daily
26. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
27. HydrOXYzine 25 mg PO QHS:PRN itching
28. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN sob/wheezing
29. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
aspiration pneumonia
metastatic pancreatic cancer
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
PA AND LATERAL CHEST, ___
HISTORY: An ___ man with pancreatic adenocarcinoma after respiratory
failure.
IMPRESSION: AP chest compared to ___:
Heterogeneous opacification at the base of the right lung which worsened
substantially after ___, has subsequently improved, still accompanied
by a small pleural effusion. Time course is consistent with either resolving
pneumonia or atelectasis.
Left lung is grossly clear. Heart size normal. Small bilateral pleural
effusions, right greater than left, are collected posteriorly, and on the
right along the lateral chest wall.
Radiology Report
INDICATION: Possible aspiration pneumonia.
COMPARISON: None available.
FINDINGS: This exam was performed in conjunction with the speech and swallow
division. Multiple consistencies of barium were administered. There was no
evidence of aspiration or penetration. The esophagus was examined, and there
was holdup of barium at the distal esophagus with significant residual barium
within the esophagus, which eventually passed into the stomach after a few
minutes. After more barium was administered, hold up was again seen, which
did not pass into the stomach after several minutes. There were multiple
tertiary contractions.
IMPRESSION:
1. No evidence of aspiration or penetration. For further details please refer
to speech and swallow division note in OMR.
2. Hold up of barium within the distal esophagus, cannot rule out stricture or
extrinsic compression of the distal esophagus. Endoscopy recommended.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: An ___ man with aspiration pneumonia and metastatic
pancreatic carcinoma. Followup.
IMPRESSION: PA and lateral chest compared to ___ through ___:
A tortuous but not particularly dilated esophagus retains contrast agent from
the preceding swallowing examination. The distal esophagus has a sharp
tapering, and could be occluded either by stricture or mass, better evaluated
during fluoroscopic observation earlier.
There is no pneumonia. A small right pleural effusion or pleural thickening
has been present since at least middle of ___. Heart size is normal.
Irregular opacification of the lungs suggests severe emphysema, on the right.
Radiology Report
HISTORY: ___ with persistent dyspnea on exertion and metastatic
pancreatic cancer, evaluate for PE.
COMPARISON: CT abdomen and pelvis ___, CTA chest ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen in the early arterial phase after administration of
150 cc of Omnipaque. . Multiplanar reformatted images in the coronal and
sagittal planes were generated. Oblique MIP's were prepared in an
independent work station.
FINDINGS:
CT of the thorax: There are multifocal areas of consolidations involving the
left upper and lower lobes. Additionally, there is a consolidation or partial
lung collapse involving the right lower lobe. There is a stable
nonhemorrhagic left pleural effusion. There are prominent bronchovascular
bundles raising the concern for lymphatic involvement of the patient's primary
malignancy.
There is significant dilation of the distal esophagus, the stomach distally is
collapsed.
CTA thorax: There is atherosclerotic disease of the abdominal aorta. The
aorta is normal in caliber throughout the thorax without intramural hematoma
or dissection. The pulmonary arteries are opacified to the segmental level.
There is no filling defect to suggest pulmonary embolism.
Osseous structures:. There are no concerning lytic or sclerotic bony lesions.
Although this study is not designed for assessment of the intra-abdominal
structures, multiple liver lesions appear stable.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Significant dilation of the distal esophagus and multifocal opacities
involving the left upper and left lower lobe as well as a consolidation or
partial collapse of the right lower lobe, finding suggest aspiration.
3. Stable nonhemorrhagic left pleural effusion.
4. Multiple hepatic metastases appear stable.
5. Prominence of the bronchovascular bundles within the lungs raise the
question of lymphatic involvement of the patient's primary malignancy.
Finding were telephoned to Dr. ___ by Dr. ___ on ___ at
11:30, 10 min after there discovery.
Radiology Report
HISTORY: Metastatic pancreatic cancer, now with increasing distention and low
ostomy output. Evaluate for bowel obstruction.
COMPARISON: CT abdomen/pelvis from ___ and portable abdominal
radiograph from ___.
FINDINGS:
Three frontal abdominal radiographs again demonstrate severely dilated
air-filled loops of large bowel, measuring up to 8 cm, with a paucity of small
bowel loops. The colonic dilation is less extensive, primarily in the right
colon, compared to ___. There is residual radiopaque oral
contrast within the loops of large bowel. No pneumatosis or free air is
visualized. Generalized increased opacity of the abdomen may be secondary to
ascites.
IMPRESSION:
1. Dilated loops of large bowel, less extensive compared to ___.
2. Ascites.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: DYSPNEA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 98.7
heartrate: 120.0
resprate: 28.0
o2sat: 96.0
sbp: 103.0
dbp: 58.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is an ___ with PMHx metastatic pancreatic
adenocarcinoma and reactive airway disease who presented with
subacute worsening dyspnea. CXR and clinical status was
consistent with pneumonia.
# Respiratory Distress
History of worsening dyspnea over several weeks with acute
worsening over last few days. Story is most consistent with
pneumonia and bronchospasm. Not overloaded and normal BNP so
does not appear to be CHF. PE a possibility given current
malignancy but does not fit with his history. Treated for
CAP/HCAP with vancomycin, levofloxacin, and cefepime. After 5
days of IV antibiotics, CXR showed improvement and his O2
saturations had improved so he was switched to PO cipro for
another 6 days. Continued on bronchodilators throughout. Sputum
cultures were contaminated with respiratory flora. Blood
cultures were negative. Given his history of asthma he was given
a 5 day course of prednisone. Based on the fact his pneumonia
seemed to be improving yet he continued to have symptoms, he had
CTA ___ which showed no PE but did show signs of aspiration as
well as concern for lymphangitic spread of cancer. Both of these
are likely contributing to his symptoms. In addition his
abdominal ascites, which has not been sampled but is presumably
due to his metastatic pancreatic cancer, may be causing
restriction of his breathing as well. He has obstructive sleep
apnea and was continued on CPAP nightly for this.
# Esophageal dysmotility: pt had EGD ___ to evaluate
possibility of stricture/obstruction/achalasia seen on video
swallow eval. LES was patent with no indication for stenting.
stomach may have tumor infiltration. he likely has esophageal
dysmotility leading to chronic aspiration. He can have a regular
diet but should take aspiration precautions such as sitting up
when eating, taking small bites and allowing plenty of time for
them to pass through his esophagus and stomach.
# Metastatic Pancreatic Adenocarcinoma
recently diagnosed, no treatment yet. Dr. ___ I have
discussed treatment with him several times during this
admission. He is not interested in getting chemotherapy that is
only expected to add a few months to his life (chemo would not
be curative). He will be treated supportively for symptoms that
may arise from his cancer. He currently has ascites which is
more than on admission. we discussed a paracentesis for comfort,
but the ascites is not currently causing him much discomfort so
he deferred. He was seen in consultation by the palliative care
team with adjustments to his pain meds (now on MSContin 15 BID
and morphine ___ for breakthrough pain). He is aware that he will
continue to decline as his cancer progresses but did not feel
ready to make plans for hospice yet. He would like to focus on
regaining strength and returning home to get his affairs in
order.
# Constipation
Patient was recently admitted for constipation. ON this
admission he had days of low ostomy output followed by several
large stools. He is on senna and colace daily with several other
laxatives PRN.
# Depression
- continued sertraline and buproprion
# Hypothyroidism
- continued home 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.
____________________________________
___, MD, pager ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
wound drainage
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ male presents after L4-L5 lumbar fusion and laminectomy with
spinal wound drainage. The patient had an uncomplicated surgery
and post-operative course. At one week follow up he was noted to
have wound drainage. A wound vac was placed. Today he presents
to the ED because his Praveena wound back has reached capacity.
He denies lower extremity numbness, weakness, saddle anesthesia,
loss of bowel/bladder control, fevers, headache, chest pain,
shortness of breath, nausea, and other medical complaints.
Past Medical History:
none
Social History:
SH: Patient lives in ___. Denies tobacco and ilicit
drug use.
Physical Exam:
NAE overnight. Afebrile. VSS. Inflammatory indices mildly
elevated c/w perioperative period.
Wound vac output zero
Main complaint is some spasm like pain in his left buttock
No headaches
PE:
98.3
PO 126 / 73 66 16 97 Ra
NAD, A&Ox4
nl resp effort
RRR
wound vac with good seal, no drainage, sponge dry
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 01:19PM BLOOD WBC-10.1* RBC-3.36* Hgb-11.0* Hct-33.0*
MCV-98 MCH-32.7* MCHC-33.3 RDW-13.4 RDWSD-47.8* Plt ___
___ 01:19PM BLOOD Neuts-70.0 Lymphs-18.2* Monos-7.0 Eos-2.3
Baso-0.7 Im ___ AbsNeut-7.04* AbsLymp-1.83 AbsMono-0.70
AbsEos-0.23 AbsBaso-0.07
___ 01:19PM BLOOD Plt ___
___ 01:19PM BLOOD ___ PTT-30.6 ___
___ 01:19PM BLOOD Glucose-111* UreaN-14 Creat-0.6 Na-142
K-5.1 Cl-103 HCO3-26 AnGap-13
___ 01:19PM BLOOD CRP-7.4*
___ 01:27PM BLOOD ___ pO2-82* pCO2-43 pH-7.44
calTCO2-30 Base XS-4
Medications on Admission:
Medications - Prescription
CEPHALEXIN - cephalexin 500 mg capsule. 1 capsule(s) by mouth
four times a day
CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for muscle spasm this
medicine may cause drowsiness
GABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth
three times a day
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every
___
hours as needed for pain Do not drive or operate heavy machinery
while taking this medication
Medications - OTC
ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1
(One) tablet(s) by mouth once a day - (Prescribed by Other
Provider; Dose adjustment - no new Rx)
IBUPROFEN [ADVIL] - Advil 200 mg tablet. 2 (Two) tablet(s) by
mouth every six (6) hours as needed for pain (will stop 1 week
preop) - (Prescribed by Other Provider; Dose adjustment - no
new
Rx)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
may take over the counter
2. Cyclobenzaprine 5 mg PO TID
may cause drowsiness
3. Docusate Sodium 100 mg PO BID
please take while taking narcotics
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
4. Methylprednisolone Dose Pack mg PO DAILY
Take as Directed
This is dose # of tapered doses
RX *methylprednisolone [Medrol (Pak)] 4 mg Dose Pack tablets(s)
by mouth Daily Disp #*1 Dose Pack Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
please do not operate heavy machinery, drink alcohol or drive
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
6. Cephalexin 500 mg PO Q6H
7. Gabapentin 300 mg PO TID nerve pain
Discharge Disposition:
Home
Discharge Diagnosis:
post operative seroma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: History: ___ with recent TLIF of L4-L5 and increased wound
drainage. Question of infection.
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 7 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: Lumbar spine MRI without contrast from ___.
Lumbar spine radiographs from ___.
FINDINGS:
Localizer sequence demonstrates 7 cervical, 12 thoracic, and 5 lumbar-type
vertebrae.
The localizer sequence and sagittal images through the thoracic spine
demonstrate a disc herniation extending inferiorly, plus/minus endplate
osteophytes, severely narrowing the spinal canal at C6-C7. No axial images
through this level. The localizer sequence also demonstrates endplate
osteophytes moderately narrowing the spinal canal at C5-C6, without diagnostic
sagittal or axial images through this level.
THORACIC:
No evidence for diskitis, osteomyelitis, epidural collection, or paravertebral
collection. Mild anterior wedging of multiple mid thoracic vertebral bodies
without marrow edema. No subluxation. No pathologic intrathecal contrast
enhancement. The conus medullaris terminates at T12-L1.
T1-T2: Small central disc protrusion mildly narrows the spinal canal.
T2-T3: Disc bulge and right paracentral disc protrusion mildly narrowing the
spinal canal. The right ventral spinal cord is mildly remodeled without cord
signal abnormality.
T3-T4: Right paracentral disc protrusion remodels the right ventral cord
without cord signal abnormality.
T4-T5: Small right paracentral disc protrusion approaches the ventral spinal
cord without cord signal abnormality.
T5-T6: Right far paracentral/foraminal disc protrusion minimally indents the
ventral thecal sac and narrows the proximal right neural foramen.
T6-T7: A disc bulge minimally indents the ventral thecal sac.
T7-T8: Central disc herniation extends superiorly above the disc space to the
right of midline, mildly remodeling the right ventral spinal cord. Evaluation
of cord signal at this level is limited, and mild T2 hyperintensity cannot be
excluded.
T8-T9: Central disc herniation mildly indents the ventral thecal sac.
T9-T10: Large central disc herniation remodels the ventral spinal cord with
mild to moderate spinal canal narrowing. Subtle T2 hyperintensity in the cord
cannot be excluded.
T10-T11: Minimal disc bulge and mild facet arthropathy without significant
spinal canal narrowing. Mild right neural foraminal narrowing.
T11-T12, T12-L1: No significant spinal canal or neural foraminal narrowing.
LUMBAR:
The patient is status post anterior fusion of L4 and L5 with an intervertebral
graft, as well as laminectomies and instrumented posterior fusion of L4 and L5
with bilateral pedicle screws. The hardware is not assessed by MRI. Grade 1
anterolisthesis of L4 on L5 is unchanged compared to the ___
radiographs and the ___ MRI. There is a fluid collection without
evidence for rim enhancement extending from the laminectomy beds through a
thin midline tract between the posterior paravertebral muscles into the
subcutaneous soft tissues. It measures 5.4 cm craniocaudad on image 15:10,
and 2.8 cm transverse on image 16:31. The collection has a large area of
surface contact with the dorsal thecal sac. There is surrounding contrast
enhancement in the posterior paravertebral muscles. The collection mildly to
moderately narrows the thecal sac at the level of L5.
Left-sided intrathecal nerve roots from mid L5 through S1 levels appear mildly
clumped without definite contrast enhancement, compatible with arachnoiditis.
L1-L2: Disc bulge and facet arthropathy mildly narrow the thecal sac without
mass effect on the intrathecal nerve roots. Mild right and moderate left
neural foraminal narrowing. This is similar to the prior MRI.
L2-L3: Disc bulge, left paracentral disc herniation extending inferiorly, and
facet arthropathy are present. Traversing left L3 nerve root is contacted in
the subarticular zone. The thecal sac is mildly to moderately narrowed with
mild crowding of the intrathecal nerve roots. Moderate bilateral neural
foraminal narrowing. This is similar to the prior MRI.
L3-L4: Mild disc bulge. Moderate facet arthropathy. No significant spinal
canal narrowing. Moderate right neural foraminal narrowing. This is similar
to the prior MRI.
L4-L5: The disc is uncovered by the grade 1 anterolisthesis. Facet joints are
obscured by hardware related artifacts. The above-described collection in the
laminectomy beds mildly to moderately narrows the thecal sac. The neural
foramina are not optimally assessed due to hardware related artifacts, but
appear moderately to severely narrowed with mass effect on the exiting L4
nerve roots, similar to the presurgical MRI.
L5-S1: Moderate facet arthropathy. Above-described fluid collection mildly
narrows the thecal sac. No high-grade neural foraminal narrowing is seen
allowing for hardware related artifacts.
Multiple sacral nerve root sleeve diverticula are again noted.
OTHER:
Apparent 6 mm pulmonary lesion in the right lower lobe on image 12:11.
Subcentimeter cystic lesion in the right kidney.
IMPRESSION:
1. Fluid collection in the laminectomy beds at L4 and L5, extending into the
subcutaneous soft tissues, demonstrates no rim enhancement to suggest
superimposed infection, though infection cannot be definitively excluded by
MRI. Seroma is most likely, but CSF leak cannot be excluded given the large
area of contact with the dorsal thecal sac. Please correlate clinically.
2. The above described fluid collection mildly to moderately narrows the
thecal sac from L4-L5 through L5-S1 levels.
3. Mild clumping of the left intrathecal nerve roots from mid L5 through S1
levels, without definite contrast enhancement, compatible with arachnoiditis.
4. L4-L5 neural foraminal narrowing, and degenerative changes at other lumbar
levels, are similar to the ___ presurgical MRI.
5. No evidence for thoracic spine infection.
6. Multilevel degenerative changes in the thoracic spine with ventral spinal
cord remodeling at multiple levels. Faint T2 hyperintensity in the spinal
cord, compatible with subtle edema myelomalacia, cannot definitively be
excluded at T7-T8 and T9-T10.
7. Incompletely evaluated apparent severe spinal canal narrowing in the lower
cervical spine at C6-C7.
8. 6 mm pulmonary lesion in the right lower lobe.
RECOMMENDATION(S): Chest CT.
NOTIFICATION: Electronic wet reading to the emergency department was provided
at the time of final dictation at 17:35 on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Wound eval
Diagnosed with Postproc seroma of a ms structure fol a ms sys procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt
temperature: 87.7
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 115.0
dbp: 70.0
level of pain: 5
level of acuity: 3.0 | ___ is a ___ y/o male s/p L4-L5 tranforaminal
lumbar interbody fusion and laminectomy on ___ with Dr.
___. He was admitted for observation of wound drainage,
likely from a seroma. Incisional wound vac was placed overnight.
He remains Afebrile, labs not c/w infection, no headaches. Wound
vac was discontinued and a mepilex dressing was applied. He is
cleared for discharge to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / Zyprexa Zydis / Benzodiazepines
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with NASH cirrhosis, decompensated with encephalopathy and
ascites, DM, HL, HTN, normal pressure hydrocephalus admitted for
change in mental status.
.
The patient has recently experienced waxing and waning mental
status found to be secondary to normal pressure hydrocephalus.
This was initially treated with therapeutic lumbar puncture, but
to avoid ongoing problems his Neurologist recently added
acetazolamide to his regimen. This was started ___. The
patient took two doses, ___ and ___. His wife stopped the
medication after these two doses due to worsening mental status.
The patient was confused, weak, and exhausted. He was unable
to feed himself, although he was able to eat when fed by his
family. His gait also worsened, with more shuffling and
slowness. He was "confused" which his wife described as being
unable to connect and seeming "lost" from the world. He was not
incoherent, rambling, agitated, or hallucinating. He also slept
___ hours for 3 nights which is very unusual. On ___ he tried
to get out of bed and was unable to get up or lie back down.
These symptoms have occurred before in the setting of hepatic
encephalopathy.
.
The patient presented to the ED on ___ for evaluation. CXR and
non-contrast head CT were reassuring. Neurology saw him and
concluded that this was likely worsening hepatic encephalopathy
due to acetazolamide.
.
Per neurology evaluation ___:
Neuro exam significant for inattention, severe, perseveration
and both extrapyramidal and frontal components to his motor
exam, with asterixis present. There is no evidence of acutely
worsened Parkinsonism, and there have been no changes in his
Sinemet in quite some time. His troubles correlated with
starting Diamox. Diamox is relatively contraindicated in
cirrhosis because it causes metabolic alkalosis, which
exacerbates hepatic encephalopathy. While he only took 2 doses,
and his bicarb is only 20, we suspect this is the explanation
for his symptoms. He will likely improve with treatments for
hepatic encephalopathy (increased lactulose/rifaximin), and
should be followed closely by outpatient liver and neuro
physicians to ensure he does improve.
.
The patient and his wife were offered admission but declined,
hoping that stopping the medication would suffice. However, on
returning home the patient became more confused. He also had a
large watery bowel movement and was unable to control his
bowels. They represented to the ED this morning.
.
In the ED, the patient stared into the distance, did not
spontaneously speak, but when prompted was A&Ox3. No alteration
of thought process. No asterixis on exam.
.
On the floor, the patient has no complaints of pain or
discomfort. He is awake and alert, oriented x2 (hospital and
self). He is not sure why is in the hospital. His wife, who is
at the bedside, states that he has not moved his bowels since
the large watery movement last night. She did not give his
usual Senna. This is not unusual, as he usually has BMs in the
afternoon/evening and has not had lactulose so far today. He
has urinated several times without pain and has produced clear
yellow urine. He has been continent of urine. She states he
seems somewhat better, more alert, and was able to eat a full
container of grapes without prompting.
.
A full ROS is otherwise negative.
Past Medical History:
NASH Cirrhosis decompensated with encephalopathy and ascites
___ disease
Type II diabetes mellitus
Familial mediterranean fever
Depression
Right sided colitis and ileitis in ___
Hyperlipidemia
Microalbuminuria
CAD: ___ two vessel disease, s/p cath & stent on RCA and LAD,EF
72%
Right 11th rib fracture s/p mechanical fall (gait instability
from ___ in ___
Basal cell carcimona
s/p cataract surgery
s/p appendectomy
s/p tonsillectomy
Social History:
___
Family History:
Per OMR his mother died from complications of hypertension. His
father died at the age of ___. He has a son with familial
___ fever.
Physical Exam:
Admission Physical Exam:
VS: 97.9 168/80 51 20 100% RA FSBS 84
General: awake, alert, following conversation. He begins to
respond to comments appropriately but loses his train of thought
and trails off. He follows activity in the room. Grasps for
things just outside his reach.
HEENT: PERRL, EOMI not fully tested ___ patient cooperation but
full on passive gaze, OP clear with lactulose residue on tongue
and teeth, trace red blood on left upper teeth, no lesion
evident. MMM.
Neck: supple, no LAD
CV: RRR, nl S1 S2, no MRG
Resp: CTAB, no wheezes or rhonchi, bibasilar rales (slight)
Abdomen: soft, non-tender, non-distended. + BS
Extremities: warm, well-perfused, no cyanosis clubbing or
edema.
Neurological: strength ___ throughout. CN II-XII tested and
intact, III IV and VI not fully tested ___ patient cooperation.
sensation grossly normal. Gait not tested. UE minimal
cogwheeling. Continued resting tremor of right foot and right
hand.
Psych: Oriented to self, "hospital", not date. Named pen
correctly. Able to read items in the room and intepret them
appropriately (TV listing, business card). Serial 7s attempted,
he counted from 10 down to 0. Thought process linear, comments
begin appropriately, then trails off.
.
Discharge Physical Exam:
Psych: Oriented to self, name of hospital, month but not year.
Attention improved, able to answer longer questions and have
short discussion of several sentences
Neuro exam unchanged
Physical exam unchanged
Pertinent Results:
Admission Labs:
___ 05:00AM BLOOD WBC-6.0 RBC-3.88* Hgb-12.4* Hct-36.4*
MCV-94 MCH-32.1* MCHC-34.2 RDW-14.0 Plt Ct-66*
___ 05:00AM BLOOD Neuts-67.2 ___ Monos-5.1 Eos-2.5
Baso-0.9
___ 05:00AM BLOOD ___ PTT-30.2 ___
___ 05:00AM BLOOD Glucose-86 UreaN-33* Creat-1.7* Na-137
K-4.5 Cl-105 HCO3-20* AnGap-17
___ 05:00AM BLOOD ALT-25 AST-25 AlkPhos-77 TotBili-0.6
___ 05:00AM BLOOD Lipase-27
___ 05:00AM BLOOD Albumin-4.2
___ 05:07AM BLOOD Ammonia-95*
___ 05:22AM BLOOD Lactate-1.4
Discharge Labs:
___ 12:20PM BLOOD WBC-5.8 RBC-3.66* Hgb-11.7* Hct-33.8*
MCV-92 MCH-31.9 MCHC-34.5 RDW-14.1 Plt Ct-71*
___ 12:20PM BLOOD ___ PTT-31.5 ___
___ 12:20PM BLOOD Glucose-211* UreaN-32* Creat-1.6* Na-136
K-4.4 Cl-106 HCO3-19* AnGap-15
___ 12:20PM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
Microbiology:
___ urine culture no growth
___ blood culture pending
Imaging:
___ (___):
FINDINGS: There is no evidence of acute intracranial hemorrhage,
discrete masses, mass effect or shift of normally midline
structures. The ventricles and sulci are prominent consistent
with age-related involutional changes. A lacune is noted within
the right basal ganglia. Periventricular and subcortical low
attenuating regions appear consistent with sequelae of chronic
small vessel ischemic disease. Bilateral mastoid air cells and
visualized paranasal sinuses are clear.
IMPRESSION: No evidence of acute intracranial hemorrhage.
Age-related
involutional changes are noted with sequelae of chronic small
vessel ischemic disease and right basal ganglia lacune.
.
CXR (___):
Low lung volumes are noted with crowding of bronchovascular
markings. The cardiac silhouette appears accentuated by low lung
volumes. The left hemidiaphragm is elevated, a new finding of
uncertain etiology. Recommend follow up radiograph to determine
if this is a persistent or transient finding.
.
___ lumbar puncture (___):
Technique:
Risk, benefits and alternative managment were explained to the
patient and the patient signed the informed consent. The patient
was brought to the fluroscopy room and was placed on the table
in prone position. The lower back was prepped and drapped in the
usual sterile fashion. After subcutaneos administration of 1%
lidocaine, a spinal needle was place at L3-4 level using
fluoroscopic guidance. The opening pressure was 10 cmH2o. Then
10 cc of clear CSF were removed and pressure was measured again,
which was 7 cmH2o. The needle was then removed. There were no
complications. Sedation was not required.
Impression: Successful lumbar puncture. No immediate
complications.
Medications on Admission:
*carbidopa-levodopa 25 mg-250 mg 1 Tab four times a day
*escitalopram 10mg QAM
*Lantus 70 units QAM
*Humalog QID per SS (18 units at 12pm and 4pm, SS at 8AM and
8PM)
*lactulose 30 ml five times per day to achieve up to 3 BMs per
day
*omeprazole 20mg BID
*pramipexole 1 mg daily
*rifaximin 550 mg BID
*spironolactone 25 mg daily
*ferrous sulfate 325 mg BID
*Ex-Lax (sennosides) 15 mg PRN constipation
*PRN tylenol
*PRN NTG
Discharge Medications:
1. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. escitalopram 10 mg Tablet Sig: One (1) Tablet PO Q8 AM ().
3. Lantus 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous qAM.
4. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: Please take according to your
sliding scale.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO five
times a day.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. pramipexole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO Q 8 AM ().
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: Take one tablet
for chest pain, if chest pain persists after 5 minutes, take
another tablet and call your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Confusion due to hepatic encephalopathy and elevated CSF
pressures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
Indication: elevated CSF pressure.
Indication: lumbar puncture.
Comparison: none.
Technique:
Risk, benefits and alternative managment were explained to the patient and the
patient signed the informed consent. The patient was brought to the fluroscopy
room and was placed on the table in prone position. The lower back was prepped
and drapped in the usual sterile fashion. After subcutaneos administration of
1% lidocaine, a spinal needle was place at L3-4 level using fluoroscopic
guidance. The opening pressure was 10 cmH2o. Then 10 cc of clear CSF were
removed and pressure was measured again, which was 7 cmH2o. The needle was
then removed. There were no complications. Sedation was not required.
Impression:
Successful lumbar puncture. No immediate complications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ALTERED MENTAL STATUS/MED REACTION
Diagnosed with HEPATIC ENCEPHALOPATHY, CHRONIC LIVER DIS NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, PARKINSON'S DISEASE
temperature: 98.0
heartrate: 59.0
resprate: 16.0
o2sat: 100.0
sbp: 150.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ with NASH cirrhosis, decompensated with encephalopathy and
ascites, DM, HL, HTN, normal pressure hydrocephalus admitted for
change in mental status.
.
# Altered mental status: Trigger for increased encephalopathy
could be acetazolamide, infection, and/or dehydration. Imaging
in ED ruled out immediate neurologic or cardiac etiology. Liver
function unchanged, renal function slightly worse (baseline 1.5,
1.7 on presentation to ED). Patient had IVF in ED ___ without
immediate improvement in his symptoms. Of note, he did not have
3 BM/day for the last 48 hours due to disruption in his dosing
schedule. Urine culture negative. Blood cultures showed no
growth to date at time of discharge. Lactulose was provided for
3 BM/day. The patient improved rapidly and was observed to feed
himself and repsond more appropriately by the second day of his
admission.
.
# Normal pressure hydrocephalus: Per the patient's outpatient
Neurologist Dr ___ puncture on ___ successfully
increased his activity level and decreased his fatigue.
Neurology was consulted and attempted bedside lumbar puncture
without success. He was scheduled for ___ LP to drain
some CSF in an attempt to further improve his mental status.
.
# NASH cirrhosis: Diagnosed ___, followed by Dr ___.
LFTs stable. Home regimen continued. Lactulose was increased
to provide 3 BM/day given 48 hours of reduced output. Mental
status improved with this regimen.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left foot infection
Major Surgical or Invasive Procedure:
___: Left foot debridement, Bone biopsy (Dr. ___
History of Present Illness:
This is a ___ with PMHx IDDM, who presented to the emergencyroom
on ___ for a left foot infection. Patient is
approximately 1 month s/p L foot percutaneous bunion with
___ pin fixation. Patient is followed closely by Dr.
___ the podiatric surgery service and was seen ___
clinic where he was found to have a superficial pin tract
infection and 1 of the pins was pulled. Since that time he
states he developed fevers, chills, malaise. He was seen ___
clinic ___ where the another pin was removed and a large
abscess was drained. He was sent to the emergency room for
further drainage and admission for IV antibiotics. Stated his
blood sugars continue to be under control. Last A1c ___ ___ was
7.6%.
Past Medical History:
IDDM
HTN
Depression
s/p 3 Right foot surgeries
s/p Percutaneous Bunion Procedure ___.
Social History:
___
Family History:
Denies FH of heart disease, DM
Physical Exam:
Physical Exam on admission
Gen: A+Ox3, NAD
Vitals: T 9.0HR 111 BP 124/58 RR 18 100%RA
Abd: Soft, NT, ND
Resp: no respiratory distress
CV: RRR
Focused lower extremity exam: DP and ___ pulses palpable. CRT <3
seconds to all digits. Left foot with erythema, edema, warmth to
forefoot. + transverse incisions noted along the medial column.
2
stab incisions are noted to dorsal ___ interspace and medial
aspect left hallux. + purulent discharge from all incisions. No
pain to palpation. Probing noted from distal toe through area of
prior pin. Able to dorsiflex and plantarflex at ankle.
Physical Exam on admission
Gen: A+Ox3, NAD
Vitals: AVSS
Abd: Soft, NT, ND
Resp: no respiratory distress
CV: RRR
Focused lower extremity exam: DP and ___ pulses palpable. CRT <3
seconds to all digits. Left foot with wound vac ___ place. able
to flex extend all digits b/l.
Pertinent Results:
___ 12:10PM ___ COMMENTS-GREEN TOP
___ 12:10PM LACTATE-2.3*
___ 11:50AM GLUCOSE-86 UREA N-16 CREAT-1.0 SODIUM-132*
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
___ 11:50AM estGFR-Using this
___ 11:50AM CALCIUM-9.2 PHOSPHATE-2.0* MAGNESIUM-1.9
___ 11:50AM CRP-252.2*
___ 11:50AM WBC-11.7* RBC-4.68 HGB-10.2* HCT-33.5*
MCV-72* MCH-21.8* MCHC-30.4* RDW-15.9* RDWSD-40.4
___ 11:50AM NEUTS-83.2* LYMPHS-8.3* MONOS-7.2 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-9.76* AbsLymp-0.97* AbsMono-0.84*
AbsEos-0.05 AbsBaso-0.04
___ 11:50AM PLT COUNT-237
___ 11:50AM ___ PTT-31.5 ___
Pertinent Imaging:
Left foot Xray (___): Transverse osteotomy present at ___
metatarsal with no fixation ___ place. Prominent soft tissue
swelling noted
medially with open wound. Osteomyelitis impossible to exclude.
Chest Xray (___):
FINDINGS: AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
heart is
normal ___ size. There is prominence of the mediastinum which
could reflect lipomatosis though clinical correlation advised.
The mediastinal margins are sharp. Imaged osseous structures
are intact. No free air below the right hemidiaphragm is seen.
IMPRESSION: Mediastinal prominence may reflect lipomatosis
though clinical correlation is
advised.
Pathology:
Left foot ___ metatarsal bone: final report pending
Microbiology:
___ 11:56 am SWAB LEFT FOOT WOUND.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 1 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Citalopram 40 mg PO QAM
2. Humalog 60 Units Breakfast
Humalog 60 Units Lunch
Humalog 60 Units Dinner
Troujec 80 Units Breakfast
Troujec 80 Units Dinner
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Pravastatin 20 mg PO QAM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Vancomycin ___ mg IV Q 12H
RX *vancomycin 1 gram 2 vials twice a day Disp #*148 Vial
Refills:*0
6. Citalopram 40 mg PO QAM
7. Humalog 60 Units Breakfast
Humalog 60 Units Lunch
Humalog 60 Units Dinner
Troujec 80 Units Breakfast
Troujec 80 Units Dinner
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Pravastatin 20 mg PO QAM
11.Outpatient Physical Therapy
bariatric walker
LOS:13 months
Prognosis: Good
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left foot infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left foot infection. // Osteo?
COMPARISON: None
FINDINGS:
AP, lateral, obliques views of the left foot were provided. There is a
fracture through the neck of the first metatarsal. Dorsal and medial soft
tissue swelling along the forefoot without subcutaneous gas. A skin defect
along the medial forefoot is consistent with provided history of wound. No
subcutaneous gas is seen. There is callus formation along the lateral margin
of the fracture. The fracture lines appear irregular and the possibility of a
subtle osteomyelitis is impossible to exclude.
IMPRESSION:
Fracture traversing the neck of the first metatarsal with adjacent callus
formation suggesting subacute injury. Prominent soft tissue swelling noted
medially with open wound. Osteomyelitis impossible to exclude. Findings were
discussed with Dr. ___.
Radiology Report
EXAMINATION: CHEST (AP upper AND LAT)
INDICATION: ___ with left foot infection. // pre-op
COMPARISON: No priors
FINDINGS:
AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The heart is
normal in size. There is prominence of the mediastinum which could reflect
lipomatosis though clinical correlation advised. The mediastinal margins are
sharp. Imaged osseous structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
Mediastinal prominence may reflect lipomatosis though clinical correlation is
advised.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with PICC // Pt had a L PICC, ___ ___
Contact name: ___: ___ Pt had a L PICC, ___ ___
IMPRESSION:
In comparison with study of ___, is an placement of a left subclavian
PICC line extends to the mid portion of the SVC. Otherwise, no change. Again
there is prominence of the superior mediastinum, which could merely reflect
mediastinal lipomatosis.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Infection following a procedure, initial encounter, Cutaneous abscess of left foot, Oth places as the place of occurrence of the external cause
temperature: 99.0
heartrate: 111.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 58.0
level of pain: 3
level of acuity: 3.0 | The patient was admitted to the podiatric surgery service from
clinic on ___ for a Left foot infection. On admission, he
was started on broad spectrum antibiotics. He was taken to the
OR for Left foot I+D on ___. He was evaluated by
anesthesia prior to going to the OR. ___ the OR there was noted
infection to the ___ interspace so the interspace was opened.
Bone biopsy of the ___ metatarsal osteotomy site was obtained
intraop and sent to pathology. There were no adverse events ___
the operating room; please see the operative note for details.
Afterwards, pt was taken to the PACU ___ stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized. The
patient was seen by a member of the infectious disease team who
recommended the patient be discharged with IV antibiotics
specific to the patients microbiology results from cultures
taken intra-op. A wound VAC was placed on ___ which he was
discharged with to be changed by ___ Q3 days at home. His intake
and output were closely monitored and noted to be adequtae. The
patient received subcutaneous heparin throughout admission;
early and frequent ambulation were strongly encouraged. The
patient was evaluated by ___ who worked with the patient several
times on being able to keep weight off the Left foot.
A PICC line was placed with verification of proper placement on
CXR.
The patient was subsequently discharged to home on POD4 with a
wound VAC ___ place on the Left Foot and ___ services for wound
care and IV antibiotics. 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: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None this admission, but ___ s/p left VATS wedge biopsy x2
History of Present Illness:
Mr. ___ is a ___ yo male with ___ CAD s/p MI (___) w/ stent
placement, CHF (EF 40%)and bilateral pulmonary lung nodules s/p
left VATS wedge biopsy x 2 on ___. He was discharged on
___ after an uneventful post-operative course. Prior to
discharge, patient was breathing comfortably, saturating in the
low- to mid-90s on RA at rest, and his ambulatory O2 sat was
>90%. CXR post-CT pull on POD1 showed small L apical PTX and
atelectasis overlying the spine. He awoke from sleep ~6 hours
post-discharge (12am) with a "coughing fit". The paroxysm
resolved spontaneously, but he developed dyspnea afterwards,
which continued unabated. His wife paged the thoracic surgery
intern, who recommended return to care for assessment. She opted
to call ___ for transport to ___. Per EMT report, his O2 sat
was 85% on first assessment, but improved to nearly 100% with
non-rebreather.
Upon arrival at ___, Mr. ___ reported significant
improvement in his respiratory status. He reported no shortness
of breath whatsoever and no significant pain. He denied fever,
chills, chest pain, abdominal pain, diarrhea, constipation,
dysuria, or confusion.
In the ED, CXR showed increasing L mid and lower lung opacity
and stable small L apical PTX. Patient was afebrile with normal
WBC count (9.6). On arrival to the floor, patient was satting
mid- to high-90s on 4L NC.
Past Medical History:
-CAD (Cardiologist = Dr. ___ at ___), MI (___) s/p stent
placement in ___
-CHF with EF of 40% and global left ventricular wall motion
abnormalities, no reversible ischemia
-MV insufficiency
-HTN
-Cerebrovascular disease
-TIA
-BCC
-Psoriasis
-BPH
-Prostate cancer ___ (not treated, observation)
-Gout
-Hyperparathyroidism
-GERD
-Anemia
-Hiatal hernia
-OA
-Narrow angle glaucoma
-Dry eye
-Lumbar spondylosis
Social History:
___
Family History:
No known history of cancer.
Physical Exam:
VS: Tmax 98.8, Tcur 98.8, BP 135/61, HR 84, RR 20, O2 sat 95% RA
GEN: NAD, AA&Ox3
HEENT: PERRL, EOMI, MMM, OP clear
NECK: Supple, trachea midline, no cervical lymphadenopathy
CARDIAC: RRR, no m/r/g
PULM: CTAB
ABD: Soft, NT/ND
EXT: WWP, no edema, 2+ distal pulses b/l
WOUND: Chest incisions c/d/i, no erythema or induration
NEURO: Grossly intact
Pertinent Results:
Admission Labs:
___ 03:00AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.5* Hct-34.3*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.2 RDWSD-44.5 Plt ___
___ 03:00AM BLOOD Neuts-85.6* Lymphs-6.2* Monos-7.2
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.21*# AbsLymp-0.59*
AbsMono-0.69 AbsEos-0.03* AbsBaso-0.02
___ 03:00AM BLOOD ___ PTT-32.9 ___
___ 03:00AM BLOOD Glucose-186* UreaN-26* Creat-1.0 Na-136
K-4.6 Cl-98 HCO3-26 AnGap-17
___ 05:10AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
___ 03:02AM BLOOD Lactate-1.5
Discharge Labs:
___ 05:10AM BLOOD WBC-8.0 RBC-3.47* Hgb-10.9* Hct-32.2*
MCV-93 MCH-31.4 MCHC-33.9 RDW-13.2 RDWSD-44.5 Plt ___
___ 05:10AM BLOOD Glucose-164* UreaN-28* Creat-1.1 Na-136
K-4.2 Cl-98 HCO3-24 AnGap-18
Imaging:
CXR ___:
Increasing left mid and lower lung opacity could reflect
hemorrhage, aspiration infection, or asymmetrical edema.
Unchanged small left apical
pneumothorax.
CTA Chest ___:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Status post VATS wedge biopsy of the previous left lower
lobe masslike
lesion. Left lower lobe consolidation is of mixed density,
indicating pleural effusion and atelectasis. Although
attenuation of measurable fluid in the left lower lobe is
simple, a small component of hemothorax is not excluded.
3. Small left apical pneumothorax.
4. Bilateral upper lobe lesions are grossly stable in size
since ___.
CXR ___:
In comparison to ___ chest radiograph, opacities in the
left mid lung have substantially improved. Bilateral upper lobe
nodular opacities persist as well as a small left apical
pneumothorax. Interval worsening of left retrocardiac opacity,
likely due to atelectasis. Note is also made of bilateral
pleural effusions.
Medications on Admission:
1. Atenolol 25 mg PO DAILY
2. Finasteride 5 mg PO QHS
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 10 mg PO QPM
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID
7. Milk of Magnesia 30 mL PO QHS:PRN constipation
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Enalapril Maleate 10 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
12. Furosemide 20 mg PO DAILY
13. vitamin A-vit C-vit E-zinc-Cu 1 tab oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enalapril Maleate 10 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY
11. Simvastatin 10 mg PO QPM
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
cough, wheezing
Use spacer
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs IH every 4
hours Disp #*1 Inhaler Refills:*0
13. Space Chamber Plus (inhalational spacing device) 1
miscellaneous Q4H:PRN with albuterol inhaler
RX *inhalational spacing device 1 spacer every four hours Disp
#*1 Cylinder Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Shortness of breath
Atelectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with s/p VATS todayL wedge biopsy // eval ?
pneumothorax, postop changes
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ at 12:21
FINDINGS:
There is a tiny left apical pneumothorax, unchanged from prior. Bilateral
upper lobe opacities appear similar to prior. There is increased opacity in
the left mid and lower lungs. Stable cardiomediastinal contours.
IMPRESSION:
Increasing left mid and lower lung opacity could reflect hemorrhage,
aspiration infection, or asymmetrical edema. Unchanged small left apical
pneumothorax.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3AM, 2 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with multiple pulmonary nodules, ___ s/p left
VATS wedge bx x2 now w/ SOB and worsening LLL opacity on CXR. Evaluate for PE
vs hemothorax.
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, 1.0 cm; CTDIvol = 0.7 mGy (Body) DLP = 0.7
mGy-cm.
2) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 2.7 mGy (Body) DLP = 2.7
mGy-cm.
3) Spiral Acquisition 8.4 s, 32.3 cm; CTDIvol = 8.7 mGy (Body) DLP = 266.2
mGy-cm.
Total DLP (Body) = 276 mGy-cm.
COMPARISON: CT chest of ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, or dissection. There is no evidence of penetrating
atherosclerotic ulcer or aortic arch atheroma present. Calcifications of the
aortic arch are moderate. Tortuous course of the descending thoracic aorta is
re- demonstrated.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion.
Patient is status post VATS wedge biopsy of the previous left lower lobe
masslike lesion. Consolidation involving the left lower lobe is of mixed
density, suggesting a combination of pleural effusion and atelectasis in the
postoperative setting. The attenuation of the fluid appears simple, but a
small component of hemothorax is not excluded (6:135, 190). There is a small
left apical pneumothorax. The previously described large lesions in the
bilateral upper lobes are irregular and marginated with scattered
calcifications, as described in ___ (8b:34) these are grossly stable
in size, accounting for differences in slice acquisition and postoperative
left lung changes. The right upper lobe lesion measures 4.3 x 2.1 cm (6:60).
The airways are patent to the subsegmental level.
Limited images of the upper abdomen demonstrate multiple calcified gallstones,
as well as atherosclerotic disease involving the origin of the celiac trunk
and SMA. Small hiatal hernia is unchanged.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Postsurgical changes in the soft tissues of the left chest wall are noted.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Status post VATS wedge biopsy of the previous left lower lobe masslike
lesion. Left lower lobe consolidation is of mixed density, indicating pleural
effusion and atelectasis. Although attenuation of measurable fluid in the
left lower lobe is simple, a small component of hemothorax is not excluded.
3. Small left apical pneumothorax.
4. Bilateral upper lobe lesions are grossly stable in size since ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with small left apical PNX // f/u on left PNX
and effusion
IMPRESSION:
In comparison to ___ chest radiograph, opacities in the left mid lung
have substantially improved. Bilateral upper lobe nodular opacities persist
as well as a small left apical pneumothorax. Interval worsening of left
retrocardiac opacity, likely due to atelectasis. Note is also made of
bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Cough
temperature: 98.4
heartrate: 89.0
resprate: 24.0
o2sat: 96.0
sbp: 159.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ w/ multiple pulmonary nodules s/p left VATS wedge bx x2 on
___ who was discharged on POD1 and re-presented ~6 hours
after discharge with acutely worsening shortness of breath.
Prior to discharge, patient was breathing comfortably,
saturating in the low- to mid-90s on RA at rest, and his
ambulatory O2 sat was >90%. CXR post-CT pull on POD1 showed
small L apical PTX and atelectasis overlying the spine. When
patient re-presented to the ED, CXR showed increasing L mid and
lower lung opacity and stable small L apical PTX. Patient was
afebrile with normal WBC count (9.6), so there was no clinical
evidence that the CXR opacities represented pneumonia. On
arrival to the floor, patient was satting mid- to high-90s on 4L
NC. Given the acutely worsening SOB, CTA chest was obtained,
which showed L effusion and atelectasis, small L apical PTX, and
no PE. Patient was given 20mg IV Lasix x1 on ___, and was -1.3L
for the day. He was encouraged to ambulate and use IS 10x/hr. He
was weaned to RA, O2 sats in low- to mid-90s on RA, and
ambulatory O2 sats were >90%. Patient remained afebrile and WBC
count downtrended to 8.0 on HD2. Pain was well controlled on PO
oxycodone and Tylenol. CXR PA & lateral on HD2 showed markedly
improved L mid-lung opacities, minimally improved upper lung
opacities, stable small L apical PTX, and small b/l pleural
effusions. Given improvement in clinical status and improved
CXR, patient was discharged on ___ and will follow up with
Dr. ___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Demerol
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with alcoholic cirrhosis (c/b variceal bleed
and ascites), bipolar disorder, urinary retention with recent
initiation of clean intermittent catheterization who presented
to ED with altered mental status and was found to have E.coli
bacteremia. Pt was last hospitalized ___ on the liver
service with alcoholic hepatitis, acute kidney injury, altered
mental status (due to ___ and hepatic encephalopathy). During
that admission, she had failed several voiding trials and was
discharged with foley with plans to f/u with urology. She was
seen at ___ clinic for f/u. Urodynamic study revealed
hyposensitive bladder and she was taught how to self-cath at
home. She began to notice that urine was dark and orange and
experienced dysuria. Foley was placed in ED that drained frank
blood. Hct was 30 on admission and decreased to 23 (baseline
___. She received 2 units PRBCs and 2 units FFP (INR peaked
to 2.2). She was also found to be hypotensive to systolic ___
and admitted to ICU where she required ~7liter IV fluid
resuscitation, 150g iv albumin, and levophed.
Blood cultures x 2 from ___ and urine culture grew
pan-sensitive E.coli. She was initially on ceftriaxone, then
broadened to cefepime when blood cultures revealed GNR
bacteremia, and narrowed to ciprofloxacin. Urology was consulted
for hematuria and manually irrigated the foley to release blood
clots. Foley is now draining clear urine. Mental status improved
with treatment of UTI and with lactulose for hepatic
encephalopathy.
Past Medical History:
-Alcoholic cirrhosis complicated by variceal bleed (first in
___, ascites, no hx of HE
-Variceal bleed c/b arrest and multiple resuscitation attempts
-Bipolar disorder
-Umbilical herniorrhaphy with a primary repair on ___
-Peripheral neuropathy
Social History:
___
Family History:
Family History: Pertinent for a father who had arthritis. No
family history of liver disease.
Physical Exam:
ET Admission
Vitals: 97 96/61 83 18 96%RA
General: alert and appropriate, though often tangential, AAOx3,
noted to be slightly jaundiced
Skin: jaundiced, with some bruising of lower back, L upper back
HEENT: Sclera icteric, MMM, + bruising surrounding her L eye
CHEST: slight TTP along R chest wall, though minimal
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: softly distended, non-tender
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A & O x 3, CN II-XII intact, moving all extremities, no
asterixis
Discharge:
Vitals: 97 96/61 83 18 96%RA
General: alert and appropriate, though often tangential, AAOx3,
noted to be slightly jaundiced
Skin: jaundiced, with some bruising of lower back, L upper back
HEENT: Sclera icteric, MMM, + bruising surrounding her L eye
CHEST: slight TTP along R chest wall, though minimal
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: softly distended, non-tender
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A & O x 3, CN II-XII intact, moving all extremities, no
asterixis
Pertinent Results:
Admission:
___ 01:40PM BLOOD WBC-10.9# RBC-2.74* Hgb-10.2* Hct-30.8*
MCV-112* MCH-37.1* MCHC-33.1 RDW-17.7* Plt Ct-54*
___ 02:40PM BLOOD ___ PTT-37.7* ___
___ 01:40PM BLOOD Glucose-183* UreaN-51* Creat-2.3*#
Na-123* K-5.7* Cl-92* HCO3-18* AnGap-19
___ 01:40PM BLOOD ALT-16 AST-41* AlkPhos-78 TotBili-6.1*
___ 12:59AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.4*
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge:
___ 05:15AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.2* Mg-1.7
___ 05:15AM BLOOD ALT-13 AST-33 AlkPhos-71 TotBili-5.9*
___ 05:15AM BLOOD Glucose-113* UreaN-17 Creat-0.6 Na-131*
K-4.1 Cl-103 HCO3-22 AnGap-10
___ 05:15AM BLOOD ___ PTT-44.7* ___
___ 05:15AM BLOOD WBC-9.2 RBC-2.54* Hgb-8.9* Hct-26.2*
MCV-103* MCH-35.1* MCHC-34.1 RDW-18.7* Plt Ct-77*#
Radiology Report
HISTORY: Cough, confusion, fall yesterday.
TECHNIQUE: Supine AP view of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. Heart size is normal. Mediastinal and hilar contours
are likely within normal limits. There is crowding of the bronchovascular
structures with prominence of the pulmonary vascular markings likely due to a
combination of supine positioning and low lung volumes. There is mild
bibasilar atelectasis. No focal consolidation, pleural effusion or
pneumothorax is identified. No acute osseous abnormalities are seen.
IMPRESSION:
Low lung volumes with bibasilar atelectasis.
Radiology Report
HISTORY: Fall with blow to the head.
TECHNIQUE: Noncontrast MDCT axial images were acquired through the head.
Bone reconstructions and coronal and sagittal reformations are provided for
review.
COMPARISON: No relevant comparisons available.
FINDINGS: The study is somewhat limited by motion artifact. There is no acute
intracranial hemorrhage, edema, mass effect or major vascular territorial
infarct. Prominent ventricles and sulci are more than expected for the
patient's age. Basal cisterns are preserved. There is no shift of normally
midline structures. Gray-white matter differentiation is preserved. A small
hypoattenuation in the left subinsular region appears chronic and may
represent an old lacune. Mild hypoattenuation in the subcortical and
periventricular white matter is likely sequelae of chronic microvascular
ischemic disease. No calvarial fracture is identified. A non-aggressive
appearing expansile lucent lesion at the left calvarial vertex does not
transgress the inner or outer tables. It has thickened trabeculation and may
be a hemangioma (3:55). The visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear.
IMPRESSION:
1. Slightly motion limited study. No evidence of acute intracranial injury.
2. Global atrophy, more than expected for patient's age.
3. Nonagressive appearing left vertex calvarial lesion may be a hemangioma.
Radiology Report
HISTORY: Fall yesterday with neck pain and tenderness.
TECHNIQUE: Noncontrast MDCT axial images were acquired through the cervical
spine. Bone reconstructions and coronal and sagittal reformations are
provided for review.
COMPARISON: No relevant comparisons available.
FINDINGS: There is no acute fracture or malalignment. There is mild
degenerative change with a disk osteophyte complex at C5-6 which mildly
narrows the spinal canal. Uncovertebral and facet arthropathy at multiple
levels mildly-moderately narrow multiple left neural foramina. No
paravertebral hematoma is seen. Prevertebral soft tissue thickness is
maintained.
No nodules are seen in the thyroid gland. The lung apices are clear. The
visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION: No acute fracture or malalignment.
Radiology Report
INDICATION: Liver disease, status post fall. Evaluate for retroperitoneal
bleed.
COMPARISON: Ultrasounds ___ and ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness without oral or intravenous
contrast. No intravenous contrast was administered due to patient's renal
function. Coronal and sagittal reformations are provided for review.
CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar
atelectasis. There is no pleural or pericardial effusion. Hypoattenuation of
the blood pool relative to the cardiac musculature is compatible with anemia.
A small hiatal hernia is seen.
Evaluation of the intra-abdominal organs is limited without intravenous
contrast. The liver is shrunken and nodular compatible with cirrhosis. The
gallbladder is distended with large stones as seen on the prior ultrasound.
Gallbladder wall edema is nonspecific in the setting of liver disease. The
spleen is enlarged measuring 15.7 cm craniocaudally, unchanged. The
unenhanced pancreas is unremarkable. The bilateral adrenal glands are normal.
There are bilateral extrarenal pelvises. Fullness of the collecting system
bilaterally without frank hydronephrosis is likely due to marked bladder
distention.
The small and large bowel are normal in course and caliber without
obstruction. There is small- moderate non-hemorrhagic ascites in the abdomen.
There is no free air. There is no retroperitoneal hematoma. The abdominal
aorta is of normal caliber throughout. Although limited without IV contrast,
there appears to be extensive paraesophageal varices. No pathologically
enlarged mesenteric or retroperitoneal lymph nodes are identified.
CT PELVIS: The rectum and sigmoid colon are normal. The bladder is markedly
distended leading to fullness of the bilateral renal collecting systems. Air
within the bladder may be related to recent instrumentation. Correlate
clinically with patient's history. Mild bladder wall thickening may be related
to urinary tract infection. The uterus is normal. Free fluid in the pelvis is
tracking from the abdomen. There is no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There is a nondisplaced fracture of the right posterior 11th rib
(2:27) and fractures of the L3 and L4 right transverse processes. No bone
finding suspicious for infection or malignancy is seen. Non-aggressive
appearing sclerotic foci in the sacrum (2:66) and in the right iliac wing
(2:70) likely represent bone islands.
IMPRESSION:
1. No retroperitoneal bleed.
2. Marked bladder distention leading to renal pelvic fullness without frank
hydronephrosis. If the patient is unable to void, she may benefit from a
Foley catheter.
3. Air within the bladder may be due to recent instrumentation if there is
history of this. Correlate clinically, especially given patient's urinary
tract infection.
4. Acute fractures of the right posterior 11th rib and the L3 and L4 right
transverse processes.
5. Cirrhosis with small-moderate non-hemorrhagic ascites, splenomegaly and
likely paraesophageal varices.
6. Cholelithiasis.
Radiology Report
CHEST CT
HISTORY: Trauma. History of transverse process fractures and eleventh rib
fracture.
COMPARISONS: Earlier CT of the abdomen from the same day.
TECHNIQUE: Multidetector CT images of the chest were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
FINDINGS:
The lack of contrast administration is limiting for detection of vascular or
solid organ injury.
There is no pleural or pericardial effusion. There is no pneumothorax. There
is no lymphadenopathy. Contours of the great vessels appear within normal
limits. The heart is at the upper limits of normal size.
Motion artifact obscures evaluation of parenchymal detail in the inferior
lower lobes. Slight scarring is present at each lung apex. No focal opacity
worrisome for injury is identified. Patchy lower lung opacities are most
suggestive of minor atelectasis.
Prominence of the paraesophageal soft tissues at the gastroesophageal junction
suggests varices. The spleen is enlarged. The liver shows cirrhosis, which
can also explain gallbladder wall thickening and ascites. A calcified
gallstone is also present. The degree of ascites about the liver is not
significantly changed and appears low in density. Increased attenuation and
vascularity in the omentum and central mesentery can also be seen with portal
hypertension. Persistent mild fullness of each extrarenal collecting system
is noted, but substantially decreased.
There is a mildly displaced fracture of the right L3 transverse process as
well as a non-displaced right posterior eleventh rib. The vertebral body
heights and interspaces appear maintained.
IMPRESSION:
1. No evidence for injury not previously elucidated on the earlier CT of the
abdomen from the same day.
2. Decreased distention of bilateral extrarenal collecting systems.
3. Cirrhosis with evidence for portal hypertension.
Radiology Report
INDICATION: Right IJ placement.
COMPARISON: Radiograph available from ___.
FRONTAL CHEST RADIOGRAPH: A right IJ catheter terminates at the cavoatrial
junction. The heart size is top normal. The hilar and mediastinal contours
are within normal limits. There is mild pulmonary vascular congestion and
interstitial edema. There is no pneumothorax or pleural effusion.
IMPRESSION: Right IJ terminating at the cavoatrial junction.
Radiology Report
AP CHEST, 4:40 A.M., ___
HISTORY: ___ woman with alcoholic cirrhosis, Gram-negative rod sepsis
and hypoxia. Evaluate pulmonary edema.
IMPRESSION: AP chest compared to ___:
Heart is smaller and mediastinal veins are no longer distended. Some edema in
the right lower lobe has improved and there is no appreciable right pleural
effusion, on the left there is still an extensive region of infrahilar
consolidation. It should be followed to make sure it is slowly clearing
asymmetric edema rather than something focal in the left lower lobe, likely
pneumonia or even pulmonary hemorrhage. No pneumothorax. Pleural effusion is
small on the left if any. Tip of the right internal jugular line ends nearly
6 cm below the level of the carina and would need to be withdrawn 2 cm to
reposition it in the low SVC.
Radiology Report
AP CHEST 1 P.M. ___
HISTORY: A ___ woman with cirrhosis and gram-negative sepsis, now
hypoxic. Suspect pulmonary edema.
IMPRESSION: AP chest compared to ___:
Moderate-to-severe pulmonary edema continues to progress with bibasilar
predominance. Heart is top normal size. Mediastinal veins are still dilated
but improved since ___. Small bilateral pleural effusions are
presumed. Displacement of the gastric bubble presumably reflects
splenomegaly.
Right jugular line ends 5 cm below the level of the carina, would need to be
withdrawn 15 mm to be sure it is in the low SVC and not in the upper right
atrium. No pneumothorax.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: JAUNDICED
Diagnosed with URIN TRACT INFECTION NOS, HYPOSMOLALITY/HYPONATREMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.0
heartrate: 94.0
resprate: 20.0
o2sat: 100.0
sbp: 103.0
dbp: 74.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is ___ with history of Etoh cirrhosis, urinary
retention who has been self cathing for the last month who is
presenting with altered mental status and foul smelling urine
for the last three days found to have pan sensitive E.coli
bacteremia.
# E.coli bacteremia/sepsis: The patient presented with altered
mental status and dysuria, and was found to by hypotensive. She
was started on empiric Ceftriaxone out of concern for UTI (see
below), which was latered broadened to Cefepime when blood
cultures were positive for GNRs; grew out to be E.coli sensitive
to Cipro and abx were downgraded. Pt required 7L NS and 150
grams of albumin for volume resucitation, and was later also
started on Levophed for pressure support. The patient was
weaned off her Levophed and her home lasix and spironolactone
have since been restarted. The patient will complete a 14 day
course of Cipro.
# E.coli UTI: The patient was found to have pansensitive E.coli
UTI; ultimately sensitive to Cipro. The patient had been
self-cathing herself because she was having urinary retention
(see below), and it is thought that this is how she developed
her infection. The patient had CT abd/pelvis which showed
evidence of renal pelvic fullness, likely due to her urinary
retention.
# Hematuria: The patient was noted to have gross hematuria;
likely that this was multifactorial, which components of
urethral trauma due to self-cath, and hemorrhagic cystitis from
her UTI in the setting of her coagulapathy. The patient had
Foley placed. Urology was consulted due to her hematuria and
they suggested manual irrigation of Foley, as there were many
clots noted. Her hematuria improved. She will follow up with
urology.
# Hematocrit drop: The patient was noted to have a crit drop
when she first presented. She does have a history of UGIB, but
she was not clinically bleeding from GI tract. Presentation was
notable for hematuria, as described above. Her coagulopathy was
corrected with Vitamin K and FFP, and her crits were trended.
She was also given 2U PRBC.
# Coagulopathy: The patient had INR of 2.0 and platelets of 54,
likely in the setting of her cirrhosis. The patient was given
FFP and Vitamin K, as decribed above because she was having crit
drops.
# urinary retention: The patient's last hospitalization was
complicated by urinary retention and she was d/ced home with a
foley. She has been seen by the urology as an outpatient and
she was started on intermittent self cathing at home. The
patient had CT abd/pelvis done in the ED which showed evidence
of renal pelvic fullness without any clear evidence of
hydronephrosis. Urology was consulted while in house given her
hematuria (see above). She will have to follow up with urology
as an outpatient.
# hyponatremia: The patient was found to be newly hyponatremic
to 123 on presentation which improved after getting NS. Was
likeyl multifactorial due to diuretic effect as well as
decreased PO intake. The patient was fluid restricted and her
sodiuum was trended.
# toxic metabolic encephalopathy: It is likely that the
patient's altered mental status on admission was due to her
underlying sepsis. Her mental status improved while her
infection was being treated. She was continued on her home
lactulose and the patient was having daily bowel movements.
# acute renal failure: The patient initially presented with
creat bump and CT pelvis with evidence of renal pelvic fullness
in the setting of her urinary retention. Etiology likely mixed
picture in the setting possible low blood pressures and
obstruction. Creat trending down in response to fluids and
after Foley being placed.
# alcoholic cirrhosis: The patient has history of etoh cirrhosis
c/b encephalopathy, UGIB. Currently LFTs are near baseline,
Tbili on presentation noted to be 6.1. MELD on admission 28.
Once her blood pressures were stabilized, the patient was
restarted on spironlactone and Lasix, as well as her
propranolol.
# bipolar disorder: con't lithium and seroquel
# neuropathy: renally dosed gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
L percutaneous nephrostomy placement
History of Present Illness:
___ y/o M with history of depression, alcohol abuse, bladder
cancer s/p multiple TURBTs/BCG therapy, alcohol abuse, recurrent
falls, and recent left subcapsular hematoma who presented to ED
at urging of his outpatient physicians. He recently had a PCP
appointment where his Cr was found to be 4.8, from a baseline
1.5. On the way home from the doctor he stumbled and fell on the
sidewalk (outside ___) but was not injured, no LOC. He
went home (where he reports having another fall without LOC) and
then heard from his PCP the next day informing him of the
abnormal labs, at which point he was referred to the ED.
He reports normal urine output but says that his urine was
darker last week. He says that he has been feeling at his usual
state of health recently. He denies headache, vision changes,
weakness, new paresthesias, chest pain, shortness of breath, or
abdominal pain. he also denies any neck or back pain.
On arrival to the ED, initial vitals were 97.3 68 106/61 16
100%. He had a negative FAST exam. There was no gross
hydronephrosis or distended bladder on bedside u/s. Urology was
consulted and a renal U/S and CT abd/pelvis were obtained.
Urology recommended urgent PCN placement and the patient was
taken to ___ from the ED before arrival to the floor.
Additionally, in the ED his K was noted to be 5.6 (no symptoms,
no ECG changes) and he was given kayexolate with repeat K 4.6.
Head CT was unremarkable. He was started on ceftriaxone for a
presumed UTI.
Also while in the ED he began to show passive suicidal ideation
and psych was consulted. Per their evaluation, he did not meet
___ criteria. Psych will continue to follow while inpatient.
On arrival to the floor he is now s/p L PCN placement. He is
stable, denies pain.
Past Medical History:
Bladder ca as above
Cervical spine disease
DM II
HTN
CKD
BPH
ETOH abuse
Chronic pancreatitis
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS - Temp 98.4 F, BP 140/70, HR 88, R 16, O2-sat 97% RA
General: Awake, alert male lying in bed, NAD
HEENT: no scleral icterus, poor dentition, OP clear, bandage on
forehead
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory
function grossly intact.
Skin: 2 small scabs over L shin (pt aware, says they are from
recent fall), no rashes. L percutaneous nephrostomy tube noted
with bloody urine in bag. Site is dressed, exam deferred, no
pain upon minimal palpation.
Gait: Deferred due to having just returned from PCN tube
placement.
Discharge:
General: Awake, alert male lying in bed, NAD
HEENT: no scleral icterus, poor dentition, OP clear, bandage on
forehead
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory
function grossly intact.
Skin: 2 small scabs over L shin (pt aware, says they are from
recent fall), no rashes. L percutaneous nephrostomy tube noted
with clear urine in bag. Site is dressed, no erythema,
tenderness or drainage, no pain upon minimal palpation.
Pertinent Results:
Admission Labs:
___ 10:50PM BLOOD WBC-9.3 RBC-2.96* Hgb-8.7* Hct-26.8*
MCV-90 MCH-29.2 MCHC-32.3 RDW-13.3 Plt ___
___ 10:50PM BLOOD Neuts-78.0* Lymphs-13.5* Monos-6.0
Eos-2.0 Baso-0.4
___ 10:50PM BLOOD Plt ___
___ 07:44AM BLOOD ___
___ 10:50PM BLOOD Glucose-159* UreaN-91* Creat-4.8*# Na-135
K-5.8* Cl-103 HCO3-16* AnGap-22*
___ 10:50PM BLOOD ALT-14 AST-9 AlkPhos-86 TotBili-0.2
___ 10:24AM BLOOD Lactate-0.9
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 08:45 5.9 2.96* 8.7* 27.1* 92 29.5 32.2 13.5 231
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 08:45 388*1 55* 2.3* 140 4.7 ___
.
MICROBIOLOGY:
___ URINE URINE CULTURE-FINAL {BETA
STREPTOCOCCUS GROUP B} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {BETA
STREPTOCOCCUS GROUP B} EMERGENCY WARD
Imaging:
Head CT (___):
IMPRESSION: No acute intracranial process.
Renal U/S (___):
IMPRESSION:
1. New moderate left hydronephrosis and hydroureter. The
ureteric dilatation extends from the level of the renal pelvis
through its insertion on the bladder.
2. Layering debris within the left renal pelvis and proximal
ureter, possibly due to urinary stasis, although correlation
with clinical signs/symptoms of pyonephrosis is recommended.
3. Posterior bladder wall thickening, left greater than right,
likely corresponding to patient's known bladder mass.
CT Abd/Pelv (___):
IMPRESSION:
1. Interval removal of the left ureteral stent with new mild
left
hydroureteronephrosis, likely due to obstruction at the left
ureterovesicular junction from known bladder cancer along the
posterior left bladder wall. Left ureteral wall thickening and
surrounding fat stranding may be due to an underlying infectious
or inflammatory process.
2. Interval decrease in size in left subcapsular renal fluid
collection, consistent with resolving hematoma.
3. Sigmoid diverticulosis with no evidence of diverticulitis.
4. Cystic lesion in the pancreatic head is unchanged in size
since the most recent prior study, and is incompletely
characterized on this exam. Followup MRI could be considered for
further evaluation.
5. New chyluria, suggestive of injury or obstruction of the
lymphatic vessels and communication with the collecting system,
possibly due to prior urological intervention
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 100 mg PO BID
2. Finasteride 5 mg PO DAILY
3. GlyBURIDE 5 mg PO BID
4. Labetalol 200 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Terazosin 5 mg PO HS
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Simvastatin 40 mg PO DAILY
4. BuPROPion 100 mg PO BID
5. GlyBURIDE 5 mg PO BID
6. Paroxetine 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Terazosin 5 mg PO HS
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Multivitamins 1 TAB PO DAILY
12. Levofloxacin 500 mg PO Q48H
until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Alcohol abuse with multiple falls. Evaluate for acute
intracranial hemorrhage.
COMPARISON: CT head from ___.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
CTDIvol: 64 mGy.
TOTAL DLP: 2051 mGy-cm.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. Prominence of the ventricles and sulci suggests
cortical volume loss. Calcifications are seen along the bilateral carotid
siphons. The visualized portions of the paranasal sinuses and mastoid air
cells are well aerated. The middle ears are clear.
IMPRESSION: No acute intracranial process.
Radiology Report
INDICATION: History of bladder cancer, presenting with acute on chronic renal
failure. Assess for evidence of hydronephrosis versus other etiology of
obstructive uropathy.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS: The right kidney is normal in size, measuring 9.2 cm. A 6 mm cyst
is seen within the right interpolar region. There is no right-sided
hydronephrosis or hydroureter.
There has been interval removal of a left-sided nephroureteral stent. There
is new left-sided moderate hydronephrosis and full column hydroureter. Debris
is seen within the left renal pelvis and proximal ureter. There is an 8.9 x
4.9 cm collection adjacent to the left kidney, seen to be subcapsular in
location on the prior CT from ___, likely representing a
subcapsular hematoma, not significantly changed in size allowing for
differences in modality.
The bladder is somewhat collapsed and difficult to assess. Mobile debris is
seen within the dependent portion of the bladder. Probable thickening of the
left posterior bladder wall correlates to the CT finding seen on this study
dated ___, likely corresponding to the patient's known bladder
mass.
IMPRESSION:
1. New moderate left hydronephrosis and hydroureter. The ureteric dilatation
extends from the level of the renal pelvis through its insertion on the
bladder.
2. Layering debris within the left renal pelvis and proximal ureter, possibly
due to urinary stasis, although correlation with clinical signs/symptoms of
pyonephrosis is recommended.
3. Posterior bladder wall thickening, left greater than right, likely
corresponding to patient's known bladder mass.
Radiology Report
HISTORY: ___ male with bladder cancer and new hydronephrosis.
Evaluation for stone or other mass causing hydronephrosis.
COMPARISON: Comparison is made to recent prior CT of the abdomen and pelvis
from ___.
TECHNIQUE: MDCT images were obtained of the abdomen and pelvis without IV or
oral contrast. Reformatted coronal and sagittal images were also reviewed.
FINDINGS:
CT ABDOMEN WITHOUT IV CONTRAST: The bases of the lungs are clear. The lack
of intravenous contrast somewhat limits assessment of solid organs and
intra-abdominal vasculature. Given these limitations, the liver is
unremarkable with no evidence of intra- or extra-hepatic biliary ductal
dilatation. The gallbladder is normal in appearance. The spleen and
bilateral adrenal glands are normal. A 17 mm hypodensity in the head of the
pancreas (2:32)is unchanged in size since the most recent prior CT, and is
incompletely characterized on this study. No pancreatic duct dilatation is
present. The stomach, duodenum and small bowel are normal in course and
caliber with no evidence of wall thickening or obstruction. The
intra-abdominal loops of large bowel are also normal. The appendix is well
visualized in the right lower quadrant and is normal (2:61).
Since the prior study, there has been interval removal of a left ureteral
stent and decrease in size of resolving left renal subcapsular hematoma
(2:42). Mild hydroureteronephrosis with surrounding inflammatory fat
stranding and ureteral wall thickening (601B:23, 2:47) is present. The right
kidney is unremarkable with no evidence of hydronephrosis.
CT PELVIS WITHOUT IV CONTRAST: Sigmoid diverticulosis is present, with no
evidence of diverticulitis. Asymmetric left posterior wall thickening of the
urinary bladder (2:75) corresponds to the area of known bladder cancer, and
likely results in obstruction at the left ureterovesicular junction. Note is
also made of a fat fluid level in the bladder lumen compatible with chyluria
(2:74). Stranding about the distal left ureter is similar compared to the
prior study. There is no pelvic free fluid. No pelvic sidewall or inguinal
lymphadenopathy is present. Small fat containing right inguinal hernia is
noted.
OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for malignancy is
present. Multilevel degenerative changes are again seen in the lumbar spine.
IMPRESSION:
1. Interval removal of the left ureteral stent with new mild left
hydroureteronephrosis, likely due to obstruction at the left ureterovesicular
junction from known bladder cancer along the posterior left bladder wall.
Left ureteral wall thickening and surrounding fat stranding may be due to an
underlying infectious or inflammatory process.
2. Interval decrease in size in left subcapsular renal fluid collection,
consistent with resolving hematoma.
3. Sigmoid diverticulosis with no evidence of diverticulitis.
4. Cystic lesion in the pancreatic head is unchanged in size since the most
recent prior study, and is incompletely characterized on this exam. Followup
MRI could be considered for further evaluation.
5. New chyluria, suggestive of injury or obstruction of the lymphatic vessels
and communication with the collecting system, possibly due to prior
urological intervention.
Radiology Report
HISTORY: ___ y/o male with history of bladder cancer and new left sided
hydronephrosis
COMPARISON: CT abdomen ___
OPERATORS: Dr. ___, Dr. ___ (fellow) and Dr. ___
___ (resident). The attending was present and supervising throughout the
entire procedure.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
fentanyl and Versed throughout the total intra-service time of 35 min. The
patient's hemodynamic parameters were continuously monitored by an independent
___ party nurse. A total dose of 150 mcg of fentanyl and 3 mg of Versed were
used. 1% local lidocaine was also used subcutaneously.
FINDINGS:
The procedure was discussed in detail with the patient. The risks and
benefits were emphasized. Informed written consent was obtained.
When the patient arrived in the angiography suite they were placed prone on
the procedure table. The left flank was prepped and draped in usual sterile
fashion. A preprocedural time out was performed per ___ protocol.
Under sonographic guidance a posterior mid pole calyx was identified within
the left kidney. A 22 gauge cook needle was then advanced into the collecting
system. Under fluoroscopic guidance an 0.018 Nitinol wire was advanced into
the renal pelvis. The needle was then exchanged for an Accustick system. The
wire was removed and cloudy white urine drained from the catheter. Contrast
was administered into the collecting system demonstrating moderate left -sided
hydronephrosis and a mild to moderately dilated proximal left ureter.
An Amplatz wire was advanced through the Accustick sheath and coiled within
the renal pelvis. The Accustick sheath was removed and 8 ___ dilator was
used to open the tract over the Amplatz wire. This was followed by successful
placement of an 8 ___ nephrostomy tube with the pigtail locked within the
renal pelvis. Nephrostogram confirmed the location of the nephrostomy tube.
An urine sample was sent to the lab for culture.
The catheter was secured to the skin using a suture and flexitract. The
catheter was placed to external bag drainage and bandaged according to
protocol. The patient left the department in stable condition. No
complications.
IMPRESSION:
Successful placement of an 8 ___ percutaneous left -sided nephrostomy tube.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL LABS
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.3
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 106.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT & PLAN: ___ y/o M with history of depression, alcohol
abuse, bladder cancer s/p multiple TURBTs/BCG therapy, alcohol
abuse, recurrent falls, and recent left subcapsular hematoma who
presented to ED at urging of his outpatient physicians for ___
(creatinine of 4.8, from a baseline 1.5).
# ___: Presented with a Cr of 4.8 from a reported baseline of
1.5. He is well known to the Urology service given his h/o
bladder cancer s/p multiple interventions and ongoing BCG
treatment. Renal u/s showed new L hydronephrosis and hydroureter
and CT scan showed obstruction at the level of the UVJ
consistent with a stricture at the prior resection site. Given
these findings, urology recommended urgent ___ placement
of L percutaneous nephrostomy tube. His procedure was uneventful
and his Cr quickly downtrended and was 2.3 at time of discharge.
Urology will continue to follow.
# Bacturia: Found to have positive UA and started on ceftriaxone
in the ED. No leukocytosis, no apparent symptoms. ___ reported
purulent urine during L PCN placement, so he was cultured from
nephrostomy output and urine which both grew >100,000 group B
strep, with transition to levofloxacin on discharge with total
___ntibiotics.
# Alcohol abuse: Patient with h/o alcohol abuse with last known
drink just prior to arrival in ED. He was placed on a CIWA
protocol but did not score during this admission and did not
require benzodiazepines. No B12 or folate deficiencies on lab
studies. He should follow up with his PCP on discharge from
rehab who can arrange outpatient psychiatry follow up.
# Depression/Suicidal ideation: Pt reported passive SI per ED
with no plan and reportedly said "I'm not going to actually do
it." Did not meet ___ criteria per psych evaluation. On
arrival to the floor he denied suicidal ideation and was
consistently talking about future plans including "needing to
pay rent". We continued his paxil and his wellbutrin was
restarted once it was clear that he was not withdrawing. He
should follow up with psychiatrist on discharge from rehab and
outpatient social work resources.
#Gait: Patient with a history of multiple falls in the setting
of EtOH abuse, including two in the past week. Did not report
any recent changes in his gait, and it appears to be a chronic
rather than acute issue. Head CT was unremarkable. He was placed
on strict fall precautions throughout this admission. He had a
non traumatic fall inhouse and should continue to be monitored
for fall prevention in rehab.
# HTN: Stable this admission. Home losartan was held in the
setting of ___. Home labetalol was continued. Urology can assess
at follow up when to restart losartan.
# DM2: He had elevated blood sugars inhouse. His glyburide was
held inhouse. He was started on lantus 12U in house. He was
discharge on lantus and glyburide. His continued need for
insulin should be reassessed at rehab. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Penicillin V Potassium / atorvastatin
Attending: ___.
Chief Complaint:
Tachycardia, abdominal distention
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy with small bowel resection and
anastomosis
History of Present Illness:
___ with history of paroxysmal atrial fibrillation on apixaban
s/p implantable loop recorder (___), peripheral T cell
lymphoma s/p 6 cycles of CHOP (last on ___ in complete
remission, small intestinal bacterial overgrowth, and
dyslipidemia who presents with afib with RVR.
Of note, patient has been undergoing work-up for abdominal
pain/distention, flatulence, and constipation over the past few
months. She was found to have SIBO via positive breath test and
completed a 2-week course of rifaximin without significant
improvement in her symptoms. Underwent EGD in ___ showing
normal mucosa; biopsy with chronic focally active gastritis of
antral and corpus mucosa with negative H pylori staining. Small
bowel barium study in ___ showed single loop of ileum with a
short segment of mucosal wall thickening c/f infection vs
inflammation. Her PO intake has been limited in this setting and
worsened over the past 2 weeks when she developed
gastroenteritis
with nausea and vomiting. Has been very fatigued.
She reports that she woke up this AM feeling very dehydrated.
She
presented to ___ for an outpatient CT A/P for
evaluation of worsening abdominal lymphadenopathy (c/f recurrent
lymphoma) and felt clammy. She was found to have HR 150's and
was
given IV metoprolol 5mg prior to being transferred to the ___
ED.
In the ED, initial vitals were:
T97.6, HR 154, BP 105/67, SpO2 97% on RA
Exam notable for:
She is awake, alert, conversant. Irregular tachycardia, with
equal peripheral pulses, warm and well-perfused. Lungs clear to
auscultation bilaterally. Abdomen soft with minimal diffuse
tenderness. Guaiac negative.
Relevant labs:
At OSH:
WBC 6.2, Hgb 9.9
Na 129, K 3.8, Cr 0.7
Trops negative
Repeat labs here:
WBC 5.7, Hgb 9.0
Na 135, K 3.5, Cr 0.5, Ca 8.2, Mg 1.5
Trops negative
INR 2.1
Relevant imaging:
CXR showed no focal consolidation.
Consults:
EP was consulted. Given patient continued to be afib with RVR
s/p
IV metoprolol 5mg x2 with relative hypotension (SBP 80-90),
decision was made to cardiovert the patient.
Patient received:
- IV metoprolol 5mg
- 2L NSS bolus
- IV ketamine prior to cardioversion
- IV calcium gluconate 1g
- IV Mg 2g
Cardioversion was attempted with 100J, followed by 200J, and
patient converted to NSR. Admitted to Medicine for further
management.
Vitals on transfer:
T97.9, HR 98, BP 114/51, SpO2 95% on RA
Upon arrival to the floor, patient reports generalized fatigue
and persistent abdominal pain that is at baseline. Denies
palpitations or current N/V. Denies recent fevers, cough, CP,
SOB, abdominal pain, dysuria, melena/hematochezia, hematuria.
Last BM was this AM.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Peripheral T-cell lymphoma, NOS, in complete remission
SIBO s/p rifaximin
Psoriasis
Paroxysmal atrial fibrillation
HLD
Anemia
Atrial and ventricular ectopy
Social History:
___
Family History:
Father died at age ___ of emphysema. Mother died at age ___ of a
stroke. She has no siblings and no children.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 99.4 (Tm 99.4), BP: 117/61, HR: 98, RR: 21, O2 sat:
92%, O2 delivery: Ra
GENERAL: Alert and interactive, laying in bed, in NAD, breathing
comfortably on RA
HEENT: NCAT, clear oropharynx, flat JVP
CARDIAC: Irregularly irregular rhythm, normal rate, S1, S2, no
m/r/g
LUNGS: Mild bibasilar inspiratory crackles, otherwise clear
ABDOMEN: Soft, mildly distended, diffusely TTP especially in
LLQ,
+rebound tenderness
EXTREMITIES: No ___ edema
NEUROLOGIC: AOx3
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 24 HR Data (last updated ___ @ 811)
Temp: 97.8 (Tm 98.9), BP: 155/74 (112-155/61-79), HR: 94
(70-97), RR: 18, O2 sat: 99% (97-99), O2 delivery: RA
Fluid Balance (last updated ___ @ 810)
Last 8 hours Total cumulative 276ml
IN: Total 1576ml, PO Amt 120ml, IV Amt Infused 1456ml
OUT: Total 1300ml, Urine Amt 1300ml
Last 24 hours Total cumulative 1093.2ml
IN: Total 3868.2ml, PO Amt 1080ml, IV Amt Infused 2788.2ml
OUT: Total 2775ml, Urine Amt 2775ml
Physical exam:
Gen: NAD
Pulm: no respiratory distress, non-labored breathing
Abd: Softer and less distended, midline periumbilical area
tender
Wounds: midline incision healing well
Pertinent Results:
ADMISSION LABS:
===============
___ 02:30PM BLOOD WBC-6.2 RBC-3.59* Hgb-9.9* Hct-30.2*
MCV-84 MCH-27.6 MCHC-32.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 02:30PM BLOOD Neuts-72.4* Lymphs-7.4* Monos-15.7*
Eos-3.0 Baso-1.0 Im ___ AbsNeut-4.51 AbsLymp-0.46*
AbsMono-0.98* AbsEos-0.19 AbsBaso-0.06
___ 04:00PM BLOOD ___ PTT-29.4 ___
___ 02:30PM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-129*
K-3.8 Cl-90* HCO3-27 AnGap-12
___ 01:10AM BLOOD ALT-12 AST-13 AlkPhos-115* TotBili-0.6
___ 04:00PM BLOOD TotBili-0.4
___ 02:30PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Calcium-8.2* Phos-3.5 Mg-1.5* Iron-18*
___ 04:00PM BLOOD calTIBC-224* VitB12-197* Folate-8
Hapto-235* Ferritn-122 TRF-172*
___ 04:00PM BLOOD TSH-0.64
___ 04:00PM BLOOD T4-7.2
PERTINENT MICRO:
================
___ Blood culture x2: negative.
___ Urine culture: negative.
___ Blood culture x2: NGTD.
___ Urine culture: negative.
___ CMV: negative.
___ EBV: IgG positive, IgM negative.
___ C.diff: negative.
___ Stool culture: pending.
PERTINENT IMAGING:
==================
CXR ___:
Worsening bilateral pleural effusions and bibasilar atelectasis.
CXR ___:
Comparison with the study of ___, the cardiomediastinal
silhouette is
stable. Little change in the degree vascular congestion and
bilateral pleural
effusions with compressive atelectasis, more prominent on the
left. No
evidence of acute focal pneumonia.
The right upper lobe nodule and mild hilar adenopathy were much
better
evaluated on the CT scan from ___.
___ 05:38AM BLOOD Digoxin-0.4*
Radiology Report
INDICATION: ___ year old woman with h/o PTCL, NOS treated with 6 cycles of
CHOP chemotherapy ending in ___. Now with persistent abdominal bloating, with
some lymphadenopathy noted on ___ exam.// Reassess lymphadenopathy for
change concerning for recurrent lymphoma.
TECHNIQUE: PA and lateral scouts obtained prior to CT abdomen, study aborted
due to presence of residual barium in bowel loops.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
Total DLP (Body) = 1 mGy-cm.
COMPARISON: CT abdomen dated ___
FINDINGS:
Please note, this is a limited exam, study aborted due to presence of residual
barium within small and large bowel loops, that would potentially degrade
image quality.
IMPRESSION:
Limited exam-lateral and AP scouts only-due to presence of residual barium
within small and large bowel loops, that were potentially degrade image
quality.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with A fib with RVR, please assess for acute
cardiopulmonary process// History: ___ with A fib with RVR, please assess for
acute cardiopulmonary process
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old woman with paroxysmal atrial fibrillation on apixaban
and SIBO who presents with afib with RVR s/p cardioversion, with abdominal
pain.// obstruction, ileus, perforation
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Small-bowel follow-through from ___.
FINDINGS:
Retained contrast is seen in the small bowel and colon. Multiple contrast
enhanced diverticuli are seen. There are no abnormally dilated loops of large
or small bowel. There is a nonobstructive bowel gas pattern.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of perforation or obstruction. Retained orally ingested contrast
from the recent prior CT abdomen is present within nondilated large bowel
loops. Inspissated barium is also noted within innumerable colonic
diverticuli.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with hx of peripheral T cell lymphoma in complete remission
as of ___, recent small intestinal bacterial overgrowth and gastroenteritis
p/w abd pain// eval progression of mesenteric lymphadenopathy and etiology of
periumbilical pain
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 8.1 mGy (Body) DLP = 8.1
mGy-cm.
3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
4) Spiral Acquisition 14.5 s, 49.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 345.6
mGy-cm.
5) Stationary Acquisition 3.5 s, 1.0 cm; CTDIvol = 8.1 mGy (Body) DLP = 8.1
mGy-cm.
6) Spiral Acquisition 14.5 s, 49.9 cm; CTDIvol = 7.1 mGy (Body) DLP = 345.6
mGy-cm.
Total DLP (Body) = 736 mGy-cm.
COMPARISON: CT from ___..
FINDINGS:
LOWER CHEST: Bilateral pleural effusion measuring 35 mm on the right, and 13
mm on left. Mild passive atelectatic changes. An emphysematous bullae seen
in the right lung base.
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.
There is a small amounts of perihepatic free fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Multiple hypodense splenic lesions are new measuring up to 12 mm.
There is also mild splenomegaly, measuring 14 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of hydronephrosis. There is a 5 mm hypodensity of the
midpole of the right kidney, too small to characterize but likely a cyst.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is thickening of a mid
small-bowel loop spanning approximately 9 cm in length with wall thickness
measuring up to 9 mm. There is near aneurysmal dilation, which is concerning
for lymphomatous involvement. We suspect wall thickening of the terminal
ileum. There is colonic diverticulosis. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not well visualized.
LYMPH NODES: There are numerous enlarged lymph nodes in the retroperitoneum,
with largest measuring 14 mm in short axis in the left para-aortic location.
In the mesentery, multiple lymph nodes, fat stranding and edematous changes
are noted with largest lymph nodes measuring up to 18 mm in short axis.
Pelvic adenopathies are also noted, measuring up to 7 mm on the left pelvic
sidewall and 7 mm on the right. Even though these are of subcentimeter size,
they are larger than on prior study.
There is nodular thickening of the broad ligament on the left, which is also
concerning.
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. Small-bowel wall thickening with aneurysmal dilation, multiple
retroperitoneal and mesenteric lymphadenopathies, as well as enlarging pelvic
lymph nodes. Ascites and bilateral pleural effusion is noted. This
constellation of findings is highly concerning for recurrent lymphoma.
2. New splenic hypodensities, also concerning for recurrent lymphoma
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with fever and cough// eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: CT abdomen pelvis from earlier today and radiographs dated ___
FINDINGS:
There are small bilateral pleural effusions with subjacent atelectasis. No
pneumothorax. The size of the cardiac silhouette is within normal limits. An
implantable loop recorder projects over the left hemithorax.
IMPRESSION:
Small bilateral pleural effusions with subjacent atelectasis. No focal
consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with h/o peripheral T cell lymphoma w/ CT A/P
c/f LAD and bowel involvement c/w recurrence// eval for additional LAD and e/o
lymphoma
TECHNIQUE: CT chest with IV contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.8 s, 33.6 cm; CTDIvol = 6.7 mGy (Body) DLP = 212.7
mGy-cm.
Total DLP (Body) = 222 mGy-cm.
COMPARISON: PET-CT ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid gland is unremarkable.
There is no axillary lymphadenopathy.
UPPER ABDOMEN: Unremarkable.
MEDIASTINUM and HILA: A precarinal lymph node measuring 1.2 cm (03:25) and
right hilar lymph node measuring 1.0 cm (03:34) are similar in appearance in
comparison to prior PET-CT ___.
HEART and PERICARDIUM: The heart is normal in size without pericardial
effusion.
PLEURA: There are moderate bilateral pleural effusions.
LUNG:
1. PARENCHYMA: Scarring at the lung apices right greater than left. Nodular
pleural opacity at the right lung apex not definitively seen on the prior exam
measures 8 mm (series 4, image 16).
2. AIRWAYS: The central airways are patent.
3. VESSELS: There are mild atherosclerotic calcifications in the aorta.
CHEST CAGE: There are degenerative changes in the spine.
IMPRESSION:
1. Stable hilar and mediastinal lymph nodes in comparisons prior PET-CT of
___.
2. Right upper lobe pulmonary nodule measuring 8 mm. This was not
definitively seen on the prior examination. Continued surveillance is
recommended.
3. Moderate sized bilateral pleural effusions.
RECOMMENDATION(S): Updated impression was discussed with ___ M.D.
by ___, M.D. on the telephone on ___ at 11:01 am.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with edema/dilation of single loop of small
bowel. Increasing abdominal pain and tenderness.// Eval perforation
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ CT chest
FINDINGS:
Bilateral pleural effusions remain present with subjacent atelectasis. There
is no pneumothorax identified. No evidence of pulmonary edema. The size of
the cardiac silhouette is within normal limits.
No free air is visualized under the diaphragm.
IMPRESSION:
No evidence of pneumoperitoneum.
Bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of peripheral T-cell lymphoma, in
remission following CHOP in ___ was initially admitted to medicine after
being found to be inAFib with RVR during outpatient CT scan. Subsequent
imaging hasshown aneurysmal dilation and edema of her ileum along
withprogressive RP, mesenteric, and pelvic lymphadenopathy concerningfor
relapsed lymphoma. Now with new O2 requirement.// evaluate for edema,
infection
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs most recently from ___
CT from ___
FINDINGS:
Implantable loop recorder projects over the left chest, stable. Interval
increase in opacities at the lung bases bilaterally compared to chest
radiograph from ___ likely representing worsening pleural
effusions with bibasilar atelectasis. There is evidence of worsening
pulmonary vascular congestion without overt pulmonary edema.
Cardiomediastinal and hilar contours are unchanged. Right upper lobe
pulmonary nodule and mild hilar lymphadenopathy are not definitively
appreciated, better evaluated on prior CT chest from ___.
IMPRESSION:
Worsening bilateral pleural effusions and bibasilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of T cell lymphoma, course c/b
afib with RVR.// ?increased size of pleural effusions, pulmonary edema
IMPRESSION:
Comparison with the study of ___, the cardiomediastinal silhouette is
stable. Little change in the degree vascular congestion and bilateral pleural
effusions with compressive atelectasis, more prominent on the left. No
evidence of acute focal pneumonia.
The right upper lobe nodule and mild hilar adenopathy were much better
evaluated on the CT scan from ___.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 38cm ___
___ Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: Multiple prior chest radiographs most recently from ___
FINDINGS:
Interval placement of a right upper extremity PICC line with tip projecting
near the mid superior vena cava. Cardiomediastinal and hilar contours are
stable. Interval improvement of pulmonary vascular congestion. Stable small
right and improved small left pleural effusion. No definite focal
consolidation. No pneumothorax.
IMPRESSION:
Right upper extremity PICC line tip projects near the mid superior vena cava.
Radiology Report
INDICATION: ___ year old woman with T cell lymphoma with c/f recurrence as
abdominal LAD, loop of bowel seen on PET with lymphomatous involvement of
small bowel// Please take upright film, eval for signs of bowel obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Multiple prior exams, most recent radiograph dated ___.
FINDINGS:
Mildly dilated loops of small bowel, measuring up to 4.0 cm. Normal caliber
gas and stool-filled large bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Mildly dilated loops of small bowel may represent an early small bowel
obstruction versus ileus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Unspecified atrial fibrillation, Tachycardia, unspecified
temperature: 97.6
heartrate: 154.0
resprate: 18.0
o2sat: 97.0
sbp: 105.0
dbp: 67.0
level of pain: uta
level of acuity: 1.0 | ___ year old woman with history of peripheral T-cell lymphoma, in
remission following CHOP in ___, who was initially admitted to
medicine after being found to be in AFib with RVR during
outpatient CT scan. Subsequent imaging has shown aneurysmal
dilation and edema of her ileum along with progressive RP,
mesenteric, and pelvic lymphadenopathy concerning for relapsed
lymphoma. |